A 46 year old Female with Acute kidney injury
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V.Sai jaya krishna, 9th sem, Roll no-137.
46 YEAR old female a resident of Rangareddy distri ct and a agriculture labour by occupation was transferred to the general medicine OPD with
Chief complaints:
Lower back pain (at hip joint) since 10 years.
History of presenting illness:
Patient was apparently asymptomatic 10 years back then she developed bilateral hip joint pain and difficulty in walking without support.
The pain was insidious in onset, gradually progressive.
Aggrevating factors are walking, kneeling down.
Then she visited local hospital in her village.Pain relief medication was given but medicine was not taken regularly.
2 years ago the pain increased and the patient visited hospital in kharmanghat. Pain relief medication was given and medicine was taken regularly.
12 days ago she visited our hospital and was transferred to General Medicine department where indepth history was taken.
-Difficulty in bending forwards.
-Co burning sensation during micturation.
-Co weight gain since 1 year.
-Co facial puffiness 2 months.
-No history of trauma and fever
-No history of chest pain, palpitations, shortness of breath.
PAST HISTORY:
-Not a known case of DM,epilepsy, Asthma,CVA,TB.
-Known case of Hypertension (Taking medication since one year one tablet every 3 days.)
-Known case of Rheumatoid arthritis.
Menstrual History:
-Menarche at 13 years.
- Tubectomy was done 23 years ago.
-Hysterectomy was done 18 years ago.
Family history:
-No similar complaints in the family members.
Personal history:
Diet - mixed
Appetite - decreased since 10days
Sleep - adequate
Urination frequency decreased
Bowel habits normal
-No addictions
-No known drug allergies
General physical examination:
The patient is concious, coherent, cooperative .
Well oriented to time, place, person.
Moderately build and moderately nourished.
Pallor - present
Icterus - absent
Cyanosis - absent
Koilonychia - absent
Lymphadenopathy - absent
Edema - present (pitting type)
Vitals:
Temperature - afebrile.
BP - 130/90 mm of Hg.
PR - 80 bpm.
RR - 14 cycles per minute.
Spo2 - 98%
On Examination:
-> Trendelenberg sign - negative
-> Squat test - positive
-> Trendelenberg test - positive
-> Inguinal ligament tenderness - absent.
-> Hip flexion - reduction in range of motion.
-> Abduction 45°and adduction20°-30°- pain felt and range of motion reduced.
-> Internal rotation 30°and external rotation 30°-70°- pain felt and range of motion reduced.
Systemic examination:
CVS Examination - S1,S2 heard, no murmurs, no raised JVP.
Respiratory system examination - Bilateral air entry present, normal vesicular breath sounds heard.
CNS examination - normal.
Lab Investigation findings:
Hu
Provisional Diagnosis:
Acute kidney injury on CKD with Urinary tract infection.Bilateral hip osteoarthritis.Diabetes mellitus
