70 year old female with CKD

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatmen

CASE OF 70 YEAR OLD FEMALE PATIENT WITH CKD

A 70 year old female patient resident of  came to the opd with cheif complaint of fever and burning micturition since two days  

HOPI:- patient was apparently asymptomatic 1 year back then she developed  pain in the flank region associated with swelling of both legs occasionally  for that she went to doctor  and they told her that her kidneys are damaged and gave medication.

Since one month  she is having sever throbbing type of pain in flank region associated with swelling of legs upto knees ( pitting type ,), and reduced urine output and burning micturition,so she came to our opd 10 days back and diagnosed with bilateral chronic kidney failure and undergone dialysis .

Patient has history of hysterectomy 3 years back ,since then she is having body pains mostly of legs and joints,so she is using pain medication regularly( most probably NSAIDS)

PAST HISTORY:- not a know case of htn,dm,tb, asthma, epilepsy

PERSONAL  HISTORY:- diet- mixed, appetite - reduced, sleep- adequate, bowel and bladder - reduced urine output with burning micturition and constipation, addictions-none 

Family history:- not significant

GENERAL EXAMINATION 

Patient is conscious, coherent, cooperative ,well oriented to time, place, person . moderately built and moderately nourished.

NO paller,icterus, cyanosis, clubbing,koilonachia, lymphadenopathy,edema

Vitals:- bp-120/80

              Pulse rate-75 

              Temp -afebrile 

               Respiratory rate-16cycles/ min 

Systemic examination 

Cvs:- s1 s2 can be heard,no murmurs are heard

Cns- no focal neurological deficit

Rs- normal vesicular breath sounds

Abdomen-  Scaphoid,soft and no tender

Provisional diagnosis:- chronic renal failure most probably due to nasaids abuse.