62 year old female with diabetic nephropathy

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 inputs.


Chief Complaints-

~Pedal Edema since 1 month.

~Nausea and vomiting since 10 days.


History of Presenting Illness-

Patient was apparently asymptomatic 6 months back and then on routine checkup,she was found to be having kidney problem and was on medication.Since 1 month,she developed pedal edema which is insidious in onset and gradually progressive,Bilateral pitting type extending up to knees.Vomiting since 10 days associated with nausea and decreased appetite.


Past History-

No history of shortness of breath 

Decreased urine output 

History of Type 2 Diabetes since 10 years,on medication.

No history of hypertension,tuberculosis,epilepsy,asthma.


Treatment History-

On medication for diabetes since 10 years.


Personal History-

Appetite-decreased

Diet-Mixed

Bowel-Regular 

Micturition-Normal 

Known allergies-none 

Habits/addictions-none 


Family History-

Insignificant 


Menstrual History-

Insignificant 


Obstetric History-

Insignificant 


General Examination-

Pallor- yes

Icterus-no

Cyanosis-no

Clubbing of fingers and toes-no

Lymphadenopathy-no

Oedema of feet-yes

Malnutrition-yes 

Dehydration-no 


VITALS

TEMP:afebrile(98.6f)

PR:82bpm

RR:22cpm

BP:140/90mmhg

Spo2:98% at room air


SYSTEMIC EXAMINATION 

CVS:S1 S2 HEARD

CNS:NAD

RESP: normal vesicular sounds

P/A: no palpable masses 

 


Hb:6.3(12-16g/dl)

Total count:6500

Neutrophils:58%

Lymphocytes:32%

Eosinophil:5%

Monocytes:5%

Basophils:0

PCV:19.1*(40-50vol%)

MCV:92.3fl

MCH:30.4pg

MCHC:33%

RDW-CV:13.1%*(11.6-14%)

RDW-SD:44.2(39-46)

RBC:2.07millions/cc*(4.5-5.5)


RFT

UREA:73mg/dl*(12-42mg/dl)

CREATININE:5.4mg/dl*(0.9-1.3mg/dl)

Uric acid:6.4mg/dl

Calcium:9.5mg/dl

Phosphorus:3.8mg/dl

Sodium:135meq/l

Potassium:4.2meq/l

Chloride:101meq/l


Random Blood sugar-153mg/dl 


Serum iron-62ug/dl


Provisional diagnosis-

Pitting type of bilateral pedal edema due to diabetic nephropathy.


Treatment-

T-Lasix 

T-Nodosis

Injection-HAI

T-Orofer









Comments

Post a Comment

Popular posts from this blog

My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystem's CBBLE

 Learning is an everyday process, and I learned this after attending my clinical postings in the general medicine department of our college. I never thought general medicine was something I would start dreaming to pursue as my residency in the future, hopefully. I was always an average student, comparing to many students in my class, and I was pretty underconfident. However, my experience with my first patient with Diabetic nephropathy progressed to Chronic kidney disease was a turning point in my life. As I was answering questions related to diabetic nephropathy and Chronic kidney disease, our respected HOD sir asked me if I checked JVP and showed me elevated JVP which astonished me as a medical student who never attended clinical postings before. He even said, "heart failure and renal failure are like twins, always go hand in hand," which has been stuck in my mind till now and has helped me assess many patients. We later discussed the case among students and residents and t
Read more

Collation of OPD Data for PLA book draft.

 Week 1 OPD Data(April 29-April 30) https://manogynab87.blogspot.com/2023/05/pla-book-project-draft-week-1.html Week 2 OPD Data(May 1-May 7) https://manogynab87.blogspot.com/2023/05/pla-book-project-draft-opd-week-2.html Week 3 OPD Data(May 8-May 14) https://manogynab87.blogspot.com/2023/05/pla-book-project-draft-opd-week-3.html Week 4 OPD Data(May 15-May 21) https://manogynab87.blogspot.com/2023/05/pla-book-project-draft-opd-week-4.html Week 5 OPD Data(May 22-May 28) https://manogynab87.blogspot.com/2023/05/pla-book-project-draft-opd-week-5.html
Read more

57 year old male with CKD

Image
  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan A   year old male,who was farmer by occupation, came to OPD with CHIEF COMPLAINTS : • Increased abdominal pain since 10 days • SOB since 10 days • Unable to speak since 2 days HOPI: • Apparently pt was asympto
Read more