A 55 year female patient came to opd with chief complaints of generalised edema and decreased urine output

Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.


The patient’s consent was taken verbally prior to history taking and examination of her condition.

 55 year old female patient who is housewife and does household chores came to general medicine opd with chief complaints of generalised pedal edema and decreased urine output.

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 2 years ago. Then she noticed blurred vision in both eyes. She consulted a local doctor and he referred to other doctor in Hyderabad.
There she was diagnosed with diabetic retinopathy and underwent a surgery for right eye and improved her vision and was told that her left eye vision can't be improved by surgery.
And 3 months back she developed bilateral pitting type of pedal edema which is gradually progressed to present till knees.
4 days back she visited a local doctor with complaints of generalised edema and decreased urine output. There they observed serum creatinine level raised to 3.5mg/dl. Then they referred to consult in kims. 
2 days back patient visited general medicine opd with generalised edema and decreased urine output. Here, when they tested serum creatinine level was 4.1mg/dl. She was cross referred to opthalmology department.

PAST HISTORY
Patient is hypertensive and diabetic since 10 years.
Patient developed diabetes retinopathy 2 years ago.
No history epilepsy,TB,asthma.

FAMILY HISTORY - no relevant family history

PERSONAL HISTORY
Diet- mixed
Appetite - normal
Bowel movement - regular
Bladder movement - irregular
Sleep -adequate
No history of addictions

ALLERGIC HISTORY - No known allergies


DRUG HISTORY
She is on regular medication with 
Telma 40mg for hypertension
Celipizide 60mg for diabetics.

PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor 
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers 
Pedal edema - PRESENT (pitting type)

VITAL SIGNS-
Temperature: 98.6F
Pulse:60 bpm
BP: 160/80mm of hg 
Respiratory rate: 14cpm
SpO2: 98 percent
GRBS-159mg%

SYSTEMIC EXAMINATION
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs

RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Free fluid present 
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
no neck stiffness
no kerming's sign
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

PROVISIONAL DIAGNOSIS
Acute kidney injury associated with diabetes and hypertension. 


INVESTIGATIONS
Serum creatinine, colour doppler 2d echo,ECG
TREATMENT

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