70 y/o female came with chief complaint of loss of appetite since 1 month

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CHIEF COMPLAINT:

A 70 year old female who is a housewife by occupation came to OPD with chief complaints of decreased appetite since 1 month

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 1 month back, then she started to loose her appetite.

Daily routine:

She wakes up at 6:00 am and do the household chores and complete her breakfast. She eat chapatti for breakfast. And rice for lunch and dinner. Since one month she lost her appetite and didn't enjoy eating food.

PAST HISTORY:

K/C/O hypertension since 1 month on medication tab. nicardia 10mg PO BD

N/K/C/O asthma, epilepsy, DM, CAD, TB.

FAMILY HISTORY:

There is no similar complaints in the family.

PERSONAL HISTORY:

Married

Diet: mixed

Appetite: lost since 1 month

Bowel and bladder movements: regular

Micturition: normal

Sleep- adequate

GENERAL EXAMINATION:

The patient is conscious, coherent and cooperative and well oriented to time, place and person.

Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal Edema -

Dehydration-

VITALS:


Temp: 98.4°F
BP:120/0 mm Hg
PR: 86bpm
RR: 16 cycles/min
SPO2: 96% at RA

GRBS: 144mg%

SYSTEMIC EXAMINATION:

CVS:

s1 and s2 sounds +
no thrills and no murmurs heard

RS:

Dyspnea: no
Wheeze: no
position of trachea: central
vesicular breath sounds heard

ABDOMEN:

shape of abdomen: scaphoid
soft and non tender
no organomegaly detected

CNS:

conscious

normal speech 

normal gait

cranial nerves are intact

sensory system normal 

motor system normal

Gait- normal

REFLEXES: BICEPS TRICEPS SUPINATOR KNEE ANKLE

RIGHT            2+          2+             2+                 2+             2+

LEFT              2+          2+             2+                  2+           2+

Cerebellar signs:

-finger -nose -in- coordination: absent

-knee-heel-in-coordination: absent

INVESTIGATIONS:

Serum iron:

RFT:

 

LFT:

Blood sugar random:

HbsAg- Rapid:

Anti hcv antibodies- rapid:

Hiv1/2 rapid test:

USG:

USG IMPRESSION: BILATERAL GRADE 2 RPD CHANGES AND SIMPLE HEPATIC CYST.

ECG:

Chest X Ray :

PROVISIONAL DIAGNOSIS:

CRF with Hypertension.

TREATMENT PLAN:

Hemodialysis is advised

Tab. Lasix 40mg PO BD

Tab. Orofer-Xt PO OD

Tab. Shelcal 50mg

Tab. Nicardia 10mg PO BD

Tab. BioD3 PO OD