A Case of Chronic Kidney Disease

General medicine -2 

Hi ,i am K.Shreya3rd year  BDS student .
This is an online elog book to discuss our patient data after taking her concent this also reflects my patient centred online learning portfolio .

Case sheet:A 41 year old female  who was on dialysis admitted in hospital  due to continuous fever and vomitings.

Chief complaint : continuous fever   and vomitings 
Bilateral Pedal edema -10days 
Facial puffines -10days 
Easy fatiguability-10days 

History of present illness:patient was apparently asymptomatic 4yrs back  then she developed bilateral pedal edema ,facial puffiness and decreased appatite and went to local hospital where on routine investigations  Renal function tests are found derranged and underwent on 2 sessions of dialysis.

History of past illness: 
A known case of hypertension 
On medication T.METXL -25mg from 1 year 
Had Surgery of AV fistula 40 days back 


Personal History :
Occupation:homemaker
Diet.          :vegetarian
Appetite    :normal 
Sleep.        :normal
Bladder and bowels:normal and regular

Family history: No

General examinatiom :
Patient is conscious , well nourished 
Palor -No
Icterus-no
Cyanosis-no
Clubbing-no
Lymphadenopathy-no
Edema.          -no 

 Vitals:
Temperature-98.6F
Bp- 140/90
Spo2-98%
Pulse rate-86beats /min

Investigations:
Hemogram
Renal function Tests 
Liver function Tests 
Serological tests
Ultrasound of abdomen 


Provisional diagnosis:Chronic kidney disease on maintenance hemodialysis

Treatment:
questions : what is the reason for fever and vomttings ?
How frequent she should undergo dialysis?

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