Chronic renal failure with pyrexia under evaluation
A 65 year old female labourer by occupation came to opd with c/o
Generalized body edema since 15 days
Sob grade III since 10 days
Loss of appetite since 10days
Decreased urine output since 10 days
Fever since 5days on and off
burning micturation since 3days
HOPI:
Patient was apparently asymptomatic 10 years back then she had an episode of seizure and she was diagnosed with hypertension and creatinine was 2.0
She was on phenytoin 100mg OD from 10years. And nicardia 20mg for hypertension
Then 5 years back she had an another episode of seizure.
15 days back she started developing generalized edema ,facial puffiness
SOB grade III,loss of appetite,decreased urine output sinc 10 days
She came to our opd i/v/o above complaints and was tested for creatinine -13.1 and urea -202
At admission pt was drowsy with fluctuations in sensorium
Not oriented to person
So in view of ?uremic encephalopathy pt was taken immediately for dialysis
She underwent 1st dialysis on 26/04/2022
PAST HISTORY:
K/c/o HTN since 10 years
K/c/o seizures since 10 years ,on medication phenytoin 100mg OD since 5 years
Not a k/c/o DM,TB,ASTHMA
Family history:
No similar complaints
Personal history:
Diet: mixed
Appetite: normal
Bowel and bladder: regular
Sleep: adequate
General examination:
patient is conscious coherent cooperative
No pallor
No icterus
No cyanosis
No lymphadenopathy
Pedal edema present
Vitals:
Temperature: afebrile
Blood pressure: 150/90mmhg
Respiratory rate: 15cycles /min
Pulse rate: 80bpm
SYSTEMIC EXAMINATION:
CVS : S1 S2 heard
RS: BAE
CNS: NAD
P/A:soft, non tender
Provisional diagnosis:
