A 49 year old patient with ckd secondary to diabetes

Hi, This is G. Nandini a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them. 
 
DOA: 28/07/2022

CHIEF COMPLAINTS:

A 49 yr old male resident of cherlapally came to the opd with the chief complaints of pain in the right lower leg since 20 days and fever since a week .

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 yrs back  he came for  a general checkup where some blood tests were done , in which they found his creatitine level is increased and is on medication since then . 

20 days back he developed swelling in both lower legs which are pitting , insidious in onset and gradually progressive and developed till knee. 

He also has SOB since 20 days and pain in only right leg.There is right lower limb cellulitis since 20 days. 

He was on dialysis. Last time he  was dialysed  on 15 days back and again dialysed on 27/07/2022.


PAST HISTORY:

k/c/o Diabetes  and hypertension since 12 years

Not k/c/o asthma, tuberculosis, epilepsy

No previous surgeries and blood transfusions. 
 


PERSONAL HISTORY:

He is married. 

 Mixed diet. 

Appetite :Normal

Micturtion: normal

Bowel and bladder habits : normal

 alcohol and smoking history: Drinks occasionally(but stopped 5 years back) 

Sleep : Not normal (couldn't sleep since 20 days) 

FAMILY HISTORY:

Has no family h/o  HTN, TB, heart disease,cancers, epilepsy. 

Family h/o of DM (father) 

GENERAL EXAMINATION : 

Vitals :

• BP - 110/70 mmHg

• Temp. - 98°F

• SpO2 - 98%

• RR - 14 cycles/min

• PR - 86 bpm

•GRBS : 107 mg%

PALLOR : present

ICTERUS : absent

CYANOSIS :Absent

CLUBBING :Absent
 
GENERALIZED LYMPADENOPATHY :Absent

ODEMA: present in legs (bilateral) 

  
SYSTEMIC EXAMINATION :


CVS:

• S1, S2 heard

• No thrills and cardiac murmurs

RESPIRATORY SYSTEM:

• No dyspnoea, wheezing

• Postion of trachea - central

• Breath sounds - Vesicular

ABDOMEN:

• Shape  : scaphoid

• No tenderness, palpable mass, bruits

• No palpable liver and spleen

CNS:

• Conscious and coherent

• Speech - normal 

No signs of meningeal irritation

• Glass gow coma scale - 15/15

Clinical images :
ulcer -15 days back


ECG:


ULTRASOUND REPORT:

2D echo report :(29/07/2022) 
2D echo report:(30/07/2022) 













PROVISINAL DIAGNOSIS:

CKD Secondary to diabetic nephropathy? 

TREATMENT:ON 28/07/2022


ON 29/07/2022
ON 30/07/2022

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