GM Case history -2

 GM Case history -2 


August 23rd


Date of admission  - 22-01- 2021 


A 22y- old - woman  presented with  blurry vision .

 

History of Present illness 


The patient was apparently asymptomatic  8months back ,then she had blurry vision for a week  and Hypertensive ( BP 220/70mm Hg)  .Consulted to an Opthomologist , found a clot in the eye , suggested a complete body scan . 



History of Past illnes - 


No history of Weight loss.


Not a known case of HTN, CAD, Asthma, TB, Epilepsy, Thyroid disorders.

No history of surgeries and blood transfusions in the past.


 Personal History 


No history of consumption of alcohol.

History of low /minimum intake of water .


FAMILY HISTORY -


No history of DM, hypertension, CVA, CAD, Asthma, Renal disorders. Thyroid disorders in the family.


GENERAL EXAMINATION -


Patient is conscious, coherent, co-operative.

There is  no icterus.

No pallor ,cyanosis, clubbing, koilonychia or lymphadenopathy.


VITALS -

Temperature- 98.6 F 

Pulse rate- 98 bpm

Respiratory Rate- 20 cpm

BP- 230/70 mmHg 

SPO2 at room air- 98% 



SYSTEMIC EXAMINATION -


CARDIOVASCULAR SYSTEM:

Inspection:


Tactile vocal fremitus- Symmetrical 

Chest wall is bilaterally symmetrical.

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses


Palpation:

JVP: normal


Auscutation:

S1, S2 heard 

No murmurs heard 


 RESPIRATORY SYSTEM-

Position of trachea: central

Bilateral air entry +

Normal vesicular breath sounds - heard

No added sounds.


PER ABDOMEN:

No tenderness 

No palpable mass

No bruits


Bowel sounds heard.



CENTRAL NERVOUS SYSTEM:


Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

No neck stiffness 

Motor & sensory system: normal

Reflexes: present

Cranial nerves: intact



Further Tests Done -


CBP , CUE ,HIV ,HbsAg, HCV , RFT,ECG ,  USG Abd , S.Iron ,BGT 


 

Specimens collected - Blood  , urine samples . 


Reports
















Final Diagnosis -  Chronic Renal failure 

CKD on MHD ( Maintenance On Hemodialysis) 

Patient is diagnosed with Chronic Renal failure.


Treatment :

 Dialysis Twice a week 











Questions :

What are the other systemic complications in case of Chronic Renal failure other than blood clots .? 


Why did the patient was asymptomatic  with a BP over 220/70mm Hg ? 


What are the Five stages of Chronic Renal failure? 


What medications should be avoided during Dialysis?

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