Diabetic nephropathy

GENERAL MEDICINE
    
Hello all. This is Tejaswi, a third-semester medical student. This e log depicts the patient-centered approach to learning. 

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Note: This is an ongoing case and will be updated as and when we find new information.





60 yr old female with bilateral pedal oedema

Case sheet 


 A 60 yr old female from devarakonda a farmer by occupation came to hospital with a chief complaints of bilateral pedal oedema .


Chief complaint 


She came with a chief complaints of 
loss of appetite 
, vomiting and nausea from past 10 days 

History of present illness 


2 months she noticed oedema in her legs which progessed and increased the oedema gradually  spread up till her knees 

Bilateral putting type oedema , nausea and vomitings from past 10 days 
 
He had a history of diabetes from past 10 yrs and was in treatment 

 Past  ILLNESS:


Pt is not a k/c/o HTN,TB, Asthma, epilepsy.

DM from past 10 yrs


PERSONAL HISTORY

Married 

Loss of appetite 

Non veg

No habits of alcohol  consumption or smoking 

Bladder  and bladder movements regular 

Sleep normal 




TREATMENT HISTORY


Took medication insulin , and OHD 


PHYSICAL EXAMINATION:

GENERAL 

  •  Pallor - present 
  •  icterus - absent
  •  cyanosis - absent
  •  clubbing of fingers/toes - absent 
  •  dehydration - absent 
  •  lymphadenopathy
  • Oedema - mild


VITALS : 

  •  temperature - febrile  - 98.6
  •  pulse rate - 82 / min
  •  Bp- 140/80mm Hg
  • RR - 18 
  •  SPO2 - 97%
  • GRBS= 153 mg/do


SYSTEMIC EXAMINATION :


CENTRAL NERVOUS SYSTEM:
Pt, conscious, coherent, and cooperative
• Speech is normal
• no signs of meningeal irritation


CARDIOVASCULAR SYSTEM:

• S1, S2 +

RESPIRATORY SYSTEM:

BAE + NVBS

 ABDOMINAL EXAMINATION:

Nothing abnormal 


INVESTIGATIONS 

RFT:

Urea- 73

Creat- 5.4

Uric acid - 6.4 

Ca-9.5

P- 3.8

Na-135

K-4.2

Cl-111


Hemogram:

Hb-6.3 

TC- 6,500

PCV-19.1

RBC-2.07


CUE 

Alb- 1+



Serum iron

62 ug/dl


Blood grouping and rh 

O positive 


HBsAg negative 


Anti HCV antibodies 

Non reactive 


SARS-cov

Negative 



Usg abdomen 




ECG 






First session of hemodialysis on 4/3/22


Diagnosis 


Diabetic nephropathy with severe anemia  


Treatment


Hemodialysis

Tab lasix 40mg bd 

Tab orofer

Inj erythropoietin 

Tab nodosis 500mg bd 










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