Case history 2
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August 11, 2021
A 50 yr old female patient presented to opd with chief complains of facial puffiness, intermittent fever, low urine output and irregular menstrual cycle.
-Patient was admitted in the hospital with above mentioned complaints on 3rd july 2021.
-There she was diagnosed with ovarian cyst. She was recommended to undergo hysterectomy.
-During the surgery, she was diagnosed with kidney disease.
-Patient was admitted in another hospital on 12th july 2021 and she was diagnosed with AKI pulmonary odema and open hysterectomy is done.
-On 30th of July she was referred to kamineni.
Past history:
-Patient suffered from TB 20 yrs back and then she used the prescribed medication for 6 months, and the TB is treated completely.
-She has a history of one blood transfusion.
-No history of Diabetes mellitus, hypertension, asthma and epilepsy.
Personal history:
-Patient takes a mixed diet.
-Normal appetite.
-Altered sleep.
-Irregular bowel and bladder movements.
-No addictions.
Family history:
No history in the family is significant.
Treatment history:
No allergy to drugs.
General examination:
-Patient was coherent, conscious , cooperative and well oriented to the environment.
-No pallor.
-No icterus.
-No clubbing.
-No generalized Lympadenopathy.
-No cyanosis.
-Bilateral pedal oedema which is of pitting type.
Vitals:
Temperature : 101°F.
Pulse rate : 80bpm.
Blood pressure : 120/80mm of hg.
Spo2 : 98%.
Systemic examination:
Cardiovascular system-
Inspection:
Chest wall is bilateral symmetry
No visible pulsations, no scars, engorged veins.
Palpation:
JVP is normal
Auscultation:
S1, S2 heard.
Respiratory system:
Bilateral airway.
Trachea is in midline.
No added sounds.
Per abdomen:
Abdomen is soft and tender.
Bowel sounds heard.
No palpable mass or free fluid.
Central nervous system:
Patient is normal.
Reflexes are normal.
Speech is normal.
Investigations:
Pedal edema:
ECG:
Haemogram:
on 30-07-2021
RFT:
ON 1-08-2021
ON 2-08-2021
ABG:
Blood urea:
Serum electrolytes:
Final Diagnosis:
Chronic Kidney disease
Treatment:
Tab lasix 40mg PO/BD
Tab orofer XT PO/BD.
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