a 62 years male with kidney failure

December 28 2022,

NAME: Himabindhu 

Roll no. 47

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CASE PRESENTATION: A 62 years old male patient came to opd with chief complaints of nausea and vomiting since 3 days. Patient also complaints of both legs swelling, decreased urine output.

HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 10 years ago, he went to hospital for fatigue, blurred vision, shortness of breath and was diagnosed with hypertension and 4 years back with diabetes for which he was using medication.few days back he had consulted near by hospital for lower back ache and pedal edema since 2 months, irregular Micturition since 15 days and fatigability since 10 days. He was diagnosed to have bilateral renal parenchymal disease(renal failure). For which he was advised to take dialysis. The patient was anemic. Also feels nausea and vomiting since 3 days.

HISTORY OF PAST ILLNESS : No history of cough ,vomiting, shortness of breath 

No history of smiliar complaints in past.

Diabetes since 4 years, hypertension since 10 years, no history of epilepsy, tuberculosis, bronchial asthma, CAD.

PERSONAL HISTORY : 

Marital status :married

Appetite: normal

Diet : mixed

Bowel and bladder habits: regular 

Sleep: adequate 

Addictions :occasional alcoholic 

Smoking: daily smoker

No known allergies 

FAMILY HISTORY: 

Their is no significant family history.

GENERAL EXAMINATION:

Conscious, coherent, co-operative

Moderately built,nourished.

 

PALLOR: PRESENT

ICTERUS:ABSENT

CYANOSIS: ABSENT

CLUBBING OF FINGERS/TOES: ABSENT

LYMPHADENOPATHY: ABSENT

PEDAL EDEMA: PRESENT.

VITALS: 

TEMPERATURE: 98.2 F

PULSE RATE: 86 bpm

BLOOD PRESSURE: 140 /90 mm of hg

RESPIRATION RATE: 16/min

PROVISIONAL DIAGNOSIS: diabetic nephropathy.