53 Year old female patient



A 53 year old female patient came to opd with chief complaint shortness 

 of breath since 3days .decreased urine output.  

History of present illness:patient was apparently asymptomatic 10 months back.Then she developed SOB.She is brought to hospital found PH,raised creatine ,urea levels. which is Diagnosed as kidney failure.Then she underwent dialysis for every 2-3 times a week.she had two times blood transfusion  .Three days back she developed shortness of breath and decreased urinary output.

PAST HISTORY:

There was a history of HTN,NO H/O DM,ASTHMA ,TB,EPILEPSY.



Personal history:

Appetite normal

Diet:mixed

Bowel movements:regular

BLADDER:Decrease urinary output

No allergies

No addiction


Family history:

No significant family history


General examination

Patient was consious,coherent,and cooperative,well oriented with time and place.

Bp:150/90

Temperature:98F

Pulse:86

Pallor:present

Icterus:absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy:absent

Oedema:bilateral pedal oedema which is pitting type and grade 2

CVS:

Normal s1 and s2 sounds heard

No cardiac murmurs

RESPIRATORY SYSTEM

Normal vesicular breath sounds heard

Respiratory crepts present on right 



                                       




                                      



                         Spoon shaped nails













Provisional diagnosis:CKD with MHD


Comments

  1. ChandanaJanuary 20, 2022 at 9:45 PM

    Please remove the patient eyes as it may cause identification and there is identifier in USG
    Please add chest x ray image

    ReplyDelete

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