50year female with CKD

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Complaints: 

1) Pedal edema since 8 months 

2) Decreased urine output since 8 months

3) Shortness of breath since 8 months.

History of present illness: 

Patient was daily labour by occupation and at 25years of age had her 1st pregnancy . patient had delayed labour for which C section was done.( Baby weight was 2kg)

At 30 years of age , patient had second pregnancy and C section was done and Baby weight was 4 kg.patient had delayed healing of the sutures.

At 31 years of age , patient had Hysterectomy done ( No proper reason )..patient says beacuse of infection and she experienced pain abdomen at that time.

At 36 years of age..patient had increased appetite and Generalized weakness and diagnosed with Diabetes.

At 48 years of age ..patient started experiencing Generalized body pains post work and used to take pain killers from rmp and used for about 2 years 

At 50 years of age ( 8months back ) .patient had pedal edema , decreased urine output and shortness of breath for which she went to the hospital and diagnosed with renal failure and started on hemodialysis outside hospital 

Since then patient was on hemodialysis and stopped going to work.

Past history: 

Known diabetic since 14 years and on insulin

Known Hypertension and CKD since 8 months.

PERSONAL HISTORY

Diet - Mixed 

Appetite - Decreased

Sleep - Inadequate 

Bladder - Decreased urine output 

Bowel movements - Regular 

Smoker and alcohol stopped 10 years back

FAMILY HISTORY

• Not significant 

GENERAL EXAMINATION

Patient is concious , coherent , co-operative 

Well oriented to Time place person 

Thin build and moderately nourished 

• Pallor - absent 

• Icterus - Absent 

• Clubbing - Absent 

• Koilonychia - Absent 

• Lymphedenopathy - Absent 

• Pedal oedema - absent 

• JVP - Normal 

VITALS

• Temperature - 99°F 

• Pulse rate - 99bpm

• Respiratory rate - 20 cpm

• BP - 140/90 mmHg

• SPO2 - 98% on room air 

• GRBS - 146 mg/dl 

Provisional diagnosis: Chronic kidney disease on maintenance hemodialysis

With known case of diabetes and Hypertension.