A 22 YR OLD FEMALE PATIENT WITH SOB AND BLURRED VISION

 December 20

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A 22 years old female, who is a student hailing from Miryalaguda presented to the Opd with the Cheif complaint of blurred vision and shortness of breath.

HISTORY OF PRESENT ILLNESS :-

 Patient was apparently asymptomatic 1 year back

Normal routine of patient one year back :-

She used to wake up at 6.am in the morning and used to have breakfast at  8.30 am and lunch at 2.am, dinner at 8.am .

Then one year back while reading the books she experienced blurring of vision 

For which she visited the hospital. On systemic examination hypertension and kidney failure were diagnosed and dialysis was done on December 20,2020.

A month later she developed cough and pulmonary edema which were subsided on medication. Again a month later she developed shortness of breath for which she visited the opd with earlier symptom of blurred vision. 

From then she is undergoing dialysis 2 times a week 

PAST HISTORY:-

Patient is a known case of hypertension since 1 year. 

No similar complaints in the past. 

She is not a known case of tuberculosis, asthma, epilepsy,diabetes. 

PERSONAL HISTORY :-

 Appetite:normal 

Diet:mixed 

Sleep-inadequate 

Bowel movements - normal

 No addictions. 

FAMILY HISTORY :-

No similar complaints in the family. 

Drug history:

No allergy to known drugs.

GENERAL EXAMINATION :-

 Patient is conscious,coherent, cooperative. 

Pallor is present 

No cyanosis 

No lymphadenopathy 

No clubbing 

No icterus 

Bilateral pedal edema

No tremors 

Vitals:

Temp:afebrile

Pulse rate:85 beats /min. 

RR:18 cycles /min. 

 Bp:130/80mm/hg. 

SYSTEMIC EXAMINATION :-

CVS-s1 and s2 heard.

No murmurs. 

Respiratory system :bilateral airway positive. 

Position of  trachea-central. 

No vesicular breath sounds heard. 

No added sounds. 

Perabdomen-abdomen is soft and non tender. 

Central nervous system :-

Patient is conscious. 

Reflexes are normal. 

Speech is normal. 

CLINICAL IMAGES:-

Investigations:

Serum electrolytes:-

Complete blood picture :-

Serum creatinine :-

PROVISIONAL DIAGNOSIS :-

ckd on MHD. 

TREATMENT :-

TAB NICARDIA SR 20MG PO/OD 

TAB NODOSIS 500MG PO/BD 

TAB SHELCAL CT PO/OD. 

TAB. OROFER XT PO/BD. 

FLUID RESTRICTION <1L/DAY

SALT RESTRICTION <2GM/DAY