A 55 year female with CKD secondary to diabetic nephropathy

 GENERAL MEDICINE CASE (11-09-23)


Welcome and greetings to every one who are visiting my blog. This is Likitha.G of 8th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

DATE OF ADMISSION - 10/09/23


                      CASE REPORT 

 A 45 year old female housewife residing in nakrekal came to OPD with chief complaints of 1) swelling in lower limbs since 4days 

     2) shortness of breath since 4days 

     3) decreased  urine output since 1day 


HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 4 days back when she developed decresed urine output since 1 days which is insidious in onset and gradually progressive and is  associated with  bilateral swelling of lower limbs extending up to knee .which is relieved on lying down .H/O shortness of breath while walking since 3 days. C/O fever since 3 days that is relieved on medication .

C/O pain in right and left lumbar region which is nonradiating.

No H/O vomitings ,chestpain ,hematuria .

HISTORY OF PAST ILLNESS: 

K/c/o diabetes mellitus since 8 years 

K/c/o HTN since 3 days  

N/K/C/O TB, Asthma,CVD,CAD,thyroid disorders.

TREATMENT HISTORY: 

Glimiperide 2mg 

Metformin 850mg

PERSONAL HISTORY:

Married. 

Appetite - decreased 

Non vegetarian 

Bowels- regular. 

Micturition- abnormal 

Known allergies - none 

Habits /addictions :

Alcohol: occasional 

Tobacco: smoking ,stopped 7 years back

FAMILY HISTORY : 

Nothing significant

PHYSICAL EXAMINATION:

GENERAL:

Pallor is present 

No signs of icterus, clubbing of fingers or toes, malnutrition.  

Oedema of feet - present

VITALS: 

Temp- a febrile

Pulse rate -78bpm

Respiration rate-20 per min

Bp- 150/80mmhg

Spo2: 96

SYSTEMIC EXAMINATION: 

CVS: S1S2 ++ 

No thrills 

No murmurs

RESPIRATORY SYSTEM: 

Dyspnoea - yes

Wheeze -absent

Position of trachea - central 

Breath sounds - vesicular 

ABDOMEN : 

Shape of abdomen - obese

Tenderness - in right lumbar region and hypochondric region 

Palpable mass- no 

Hernial orifices - normal 

Free fluid - no 

Bruits- no 

Liver- not palpable 

Spleen - not palpable. 

Bowel sounds - yes. 

CNS: 

Level of consciousness- conscious 

Speech- normal 

Signs of meningeal irritation- none 

INVESTIGATIONS:

1) SERUM CREATININE


2) HEMOGRAM


3) BLOOD SUGAR 


4) BLOOD UREA 

5) SERUM IRON 

6) CUE


7) APPT

8) HBsAg -RAPID

9) SERUM ELECROLYTES 

10) PROTHROMBIN TIME

11) BLEEDING AND CLOTTING TIME 

12)BLOOD GROUPING AND RH TYPE 

13) ANTI HCV ANTIBODIES 

14) HIV 

15) Ultrasound 

16)ECG



 PROVISIONAL DIAGNOSIS: 

Chronic kidney disease secondary to Diabetic nephropathy with k/c/o DM since 8 years .


TREATMENT: 

1.Iv fluids NS 30 ml /hr

2. Inj.CEFTRIAXONE 1gm/iv/BD

3. Inj.LASIX  40mg/iv/BD

4. Inj.HAI subcut TID before meals 

5.Inj.PAN 40mg/iv/OD

6.Inj.ZOFER 4mg/iv/BD 

7. Tab.AMLODIPINE PO/OD

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