Case history

A 60 years old female,presented in OPD  with a chief complaint of pain in lower back region on right side since 2 years.

PRESENT ILLNESS:

- Patient  was apparentaly asymptomatic  2 years back when she noticed pain in lower back region

- Pain increased during time 

- Patient was diagnosed with a kidney problem and suggested a dialysis

- Patient also experiences SOB

- Patient is undergoing dialysis since 2 months weekly twice 

- Patient complaints of severe body pains 

 PAST HISTORY:

- Patient  accidentally had a thorn prick in left eye and was asymptomatic for 3 months and then  noticed oozing of pus .

- Patient consulted a doctor and was referred to a surgery (removal )

 - Known  case of hypertension 

- Not a Known case of CAD,Asthma, TB,Epilepsy,Thyroid disorder 

PERSONAL HISTORY:

Diet: Mixed diet 

Sleep : Adequate 

Bowel and bladder habits :Normal 

Addictions:No 

Appetite: Normal 

FAMILY HISTORY:

- No similar complaints in the family 

DRUG HISTORY :

- Patient was under medication before eye surgery

- Patient is not allergic to any Known drug

GENERAL EXAMINATION:

- Pallor -No

- Ictures-No

- Cyanosis-No

- Clubbing of fingers/toes -No

- Lymphadenopathy- No

- Edema of feet- Yes

- Malnutrition-No

VITALS:

-Pulse rate  - 88bpm

- Temperature -98.6 

-Respiratory rate- 16cpm

- B.P-140/90

PROVISIONAL DIAGNOSIS 

- Chronic renal failure 

INVESTIGATION 

-CBP 





- Blood urea 



- Serum creatinine 



-Serum Electrolytes 



TREATMENT 

-Tab.Augmintin 60mg 

-Tab.Dolo 650mg 

-Tab.Asprini 7mg 

-Tab.Pan 40mg 


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