A Case of Renal Failure

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Note: This is still an ongoing case that will be updated.

 A 42 year old female came to the hospital with chief complaints of pedal edema, shortness of breath and decreased urine output since 6 months.

HISTORY OF PRESENT ILLNESS:-

The patient was apparently asymptomatic 6 months ago and then she developed pedal edema, which was gradual in onset, progressive along with shortness of breath (grade III-IV) along with decreased urine output. She then came to this hospital for further evaluation.

HISTORY OF PAST ILLNESS:-

She is not a known case of diabetes mellitus, CVA, TB, asthma. She had hypertension since 6 months.

TREATMENT HISTORY:-

The patient had a blood transfusion in the past. She is also regularly taking medicines for her symptoms. She had a C-Section surgery 20 years ago.

PERSONAL HISTORY:-

Diet: Mixed, but ever since the onset of her symptoms, she stopped consuming non-vegetarian food.

Appetite: decreased

Bowels: irregular

Micturition: decreased

FAMILY HISTORY:-

No history of diabetes, hypertension, heart disease or stroke, tuberculosis, cancer. Patient's sibling has diabetes.

GENERAL EXAMINATION:-

The patient was conscious, coherent, and cooperative and examined in a well lit room.

    VITALS:

    . Pulse rate: 70bpm

    . respiratory rate: 23 breaths/min

    . BP: 130/80 mm Hg

    . SPO2: 98%

    PHYSICAL EXAMINATION:

    . Pallor: present

    . Icterus: absent

    . Cyanosis: absent

    . Clubbing of fingers and toes: absent

    . Lymphadenopathy: absent

    . Pedal edema: present bilaterally, upto ankle, non-pitting type

    . Malnutrition: eats less due to decreased appetite.

SYSTEMIC EXAMINATION:-

CVS: S1, S2 sounds heard.

No thrills, no murmurs.

Respiratory system: BAE+, normal vesicular breath sound present

Abdomen: Shape of abdomen - scaphoid. No tenderness, no palpable mass, no organomegaly

CNS: Conscious and normal speech, normal gait, cranial nerves normal, sensory system normal, motor system normal, no signs of meningeal irritation.

INVESTIGATIONS:-

ECG:-

Serum Iron:-

Serum Electrolytes:-

Serum Creatinine:-

Blood Urea:-

Anti HCV Antibodies - RAPID:-

HIV 1/2 Rapid Test:-

HBsAg-RAPID:-

Ultrasound Report:-

CBP:-

PROVISIONAL DIAGNOSIS:-

CKD