Case history

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A 60 yr old female .patient presented to OPD with cheif complaint of pain in the lower back region (right side) since 2 years and shortness of breath since 1 year 

HISTORY OF PRESENT ILLNESS 

patient was apperently a symptomatic when she noticed the pain in the lower back region 

Pain gradually increased during the time and it is more while walking 

Patient is undergoing dyalsis since 2 months weekly twice 

History of  SOB since a year

Patient complains of body pains  

PAST HISTORY : 

Patient had a accidental thorn pric in the left eye and asymptomatic for 3 months later she noticed the discharage of pus from the eye  

Consulted to doctor and suggested for removal of eye  

Patient is in frequent use of eye drops since 6 yrs

Patient developed pedal edema  2 months back and consulted a doctor .

History of hyper tension since 1 yr 

No history of DM  epilepsy etc..

PERSONAL HISTORY : 

Married . 

DIET : mixed 

Appatite: normal

Sleep : adequate 

Bowl and bladder : normal 

No history of any addictions 

FAMILY HISTORY : 

 No similar complaint in the family 

TREATMENT HISTORY : 

patient was on medication before eye surgery 

Patient used pain killers for 6 yrs 

No history of allergy to known drugs 

GENERAL EXAMINATION : 

patient was well built concious coherent and well norushied 

No pallor 

No icterus

No cynosis 

Bypedal edema is present 

No lymph node enlargement 

Vitals : 

Temp : 98.6 ⁰F 

Pulse : 88 beats / min 

BP : 140/90mm hg 

Resp rate : 16 cycles / min 

SYSTEMIC EXAMINATION : 

CVS : s1 and s2 are heard 

          No cardiac murmures heard

CNS : consicious

         Speech . Normal 

Respiratory system : no wheezing 

            position of trachea: central 

Per abdomen : liver not palpable ,

                      spleen not palpable

                    ,no palpable mass in abdomen 

                     , no bowel sounds. 


INVESTIGATIONS : 

CBP :


Blood urea : 


Serum creatinin : 


Serum electrolytes: 


Complete urine examination : 



DIAGNOSIS : 

chronic kidney disease 

TREATMENT : 

dyalsis 

Tab.Augmintin 60mg 

-Tab.Dolo 650mg 

-Tab.Asprini 7mg 

-Tab.Pan 40mg 



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