A 45 yr old female patient complains of loss of appetite burning micturation and inadequate sleep
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CHIEF COMPLAINT:
A 45 yr old female patient came to the causality with a complaint of loss of appetite , burning micturation and inadequate sleep since 2months
HISTORY OF PRESENT ILLNESS: A 45 yr old female patient who agricultural labour
by occupation was apparently asymptomatic since two months then she noticed loss of appetite burning micturation and inadequate sleep
Firstly she visited near by local hospital
HISTORY OF PAST ILLNESS:
4yrs back she had undergone( right kidney )
Nephrectomy
Blood transfusion (6 packets) 3months back
No h/o hypertension, diabetes, epilepsy,
Asthma, thyroid
PERSONAL HISTORY:
married
Diet : mixed
Appetite: decreased
At present normal
Sleep : inadequate
Micturation : burning
At present normal micturation
Bowel and bladder movements : regular
Menstrual history : irregular
No addictions
No drug allergy to known drugs
FAMILY HISTORY :
No relevant family history
GENERAL EXAMINATION :
Patient is conscious coherent cooperative and well oriented to time place and person
H/o pallor unilateral pitting type of pedal edema facial puffiness
No cyanosis clubbing
Vitals :
Temp : afebrile
BP: 110/ 80
RR : 18
PR : 71
SYSTEMIC EXAMINATION :
CVS : no thrills no cardiac murmurs
S1s2sounds heard
RS :no wheeze no dysponea
Position of trachea : central
Abdomen
On inspection
Shape : distended
Scars present
Symmetrical movements of abdomen
Umbilicus : inverted
No dilated veins
On palpation
Superficial palpation : no tenderness
Warmth body
Deep palpation
Liver : palpable
No tenderness
Lower border is palpable unable to locate upper border
Spleen : palpable
No tenderness
On percussion :
No fluid thrill
No shifting dullness
Liver : dull note
Spleen : dull note
Auscultation:
Bowel sounds :10 /min
CNS : conscious
No neck stiffness
Normal speech
PROVISIONAL DIAGNOSIS: chronic kidney disease
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