50 year old female patient with CRF

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .

A 50 year old female patient came with the complaint of sob in the morning and pedal edema and facial puffinness since 2days 

HISTORY OF PRESENT ILLNESS :- 

Patient was apparently asymptomaticasymptomatic since today morning then c/o sob where she was taken to govt hospital and given medication , sob reduced 

H/o pedal edema and facial puffinness 

No H/o decreased v.o

HISTORY OF PAST ILLNESS :- 

K/c/o HTN,2 years on Nicardia 20 mgTid/Po, Diabetes mellitus, epilepsy.

K/c/o CRF, 7 months on treatment 

PERSONAL HISTORY:

No loss of appetite

Diet:mixed

Bowel movements: Regular

Addictions: Nil

FAMILY HISTORY:

No h/o similar complaints in the family

General Examination:

 

Patient is C/C/C

Pallor:Yes

Icterus:No

Cyanosis:No

Clubbing of fingers/toes:No

Lymphadenopathy:No

Oedema of feet:Yes

VITALS:

Temperature:101 F

Pulse rate:125/min

Respiration rate:22/ min

BP:150/90 

Spo2: 98%

SYSTEMIC EXAMINATION:

CVS:

Thrills: No

Cardiac sounds: S1 S2 heard and no murmurs

Respiratory system:

Dyspnoea:NO

Wheeze:NO

Position of trachea is central with added vesicular breath sound and Rhonchi adventitious sound

PER ABDOMEN:

Shape:scaphoid

Tenderness: No

Palpable mass:No

Bowel sounds : yes

Hernial orifices; Normal

Bruits:No

CNS:

No focal neurological deficits

Provisional diagnosis:

Chronic Renal Failure

Investigations:

27/03/22

ABG:

LFT:

Hemogram:

RFT:

03/04/22

CBP:

SERUM ELECTROLYTES:

BLOOD UREA:

SERUM CREATININE:

28/03/22

SERUM IRON:

27/03/22

ECG:

TREATMENT GIVEN: