A 55 year old female came to the opd with the chief complaints of bilateral pedal edema.

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A 55 yr old female resident of   and     by occupation came to the opd with the chief complaints of bilateral pedal edema since 3months and decreased urine output since 2 days.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 3 months back and then she developed bilateral pedal edema since then, which was insidious in onset and was non continuous from 3months and later swelling extended up to the knee.

She also had complaints of decreased urine output since 2 days.

Swelling was not associated with pain , or any aggravating or relieving factors.

There is no history of fever.

There is no history of burning micturion, hemeturia.

There is no history of  chest pain, breathlessness, orthopnea , pnd.

HISTORY OF PAST ILLNESS 

There were similar complaints in the past before 18 months but without decreased urine output.

The patient is a known case of diabetes and hypertension since 10years, and not a known case of tb , epilepsy , asthma, thyroid disorders.

There is no surgical history.

DRUG HISTORY/ TREATMENT HISTORY 

The patient was on t-telma , t-arkamine for and glimiperide 40mg since 10years and used regularly.

FAMILY HISTORY 

There is no significant family history.

PERSONAL HISTORY 

DIET :- mixed

APPETITE :- normal

BOWEL movements :- regular

BLADDER movements :- decreased , but better than before.

SLLEP :- adequate 

ADDICTIONS :- occasionally consumes beer nearly 100ml.

MENSTRUAL HISTORY 

She attained menopause  early before 8 years.

She attained menarche  nearly at the age of 12 years and had regular 30 days  menstrual cycle  for 5 days.

She has 3 kids.

GENERAL EXAMINATION 

Patient is examined in a well light room after taking the consent. Patient is conscious, coherent and cooperative , moderately built and moderately nourished.

Pallor , icterus, cyanosis, clubbing, koilonychia, lymphadenopathy are absent.

Pedal edema is present pitting type.

Vitals

Temperature:- afebrile 

Pulse rate:-80bpm

Respiratory rate:-18 cpm

B.P :- 140/90 mm of hg.

SYSTEMIC EXAMINATION 

CVS:- S1, S2 heard. No murmers heard

R.S:- trachea is central.

C.N.S :- no focal neurological deficits. 

              Cranial nerves are intact.

                 Reflexes are normal.

PER ABDOMEN:-  soft and non tender.

PROVISIONAL DIAGNOSIS 

Acute kidney injury of a patient with diabetes and hypertension.

INVESTIGATIONS 

CUE, Creatinine levels.

Creatinine- 4.1(0.6-1.1).

TREATMENT 

Lasix INJ  40mg  i.v,bd.

T.nicardia 10mg po,tid.

T.nodosis 500mg po,tid.

T.metxl 50mg po, tid.

HAI INJ  according to GRBS.

Bio - d3 (cap) po,od.

T.shelcal 500mg po,od.

Monocef IV 1gm, bd.

N.s according to the urine output+30ml per hr.

16-12-2022

S- urine output improved than that observed on admission.

 no new complaints.

O-  grbs:- 110mg/dl.

      b.p:- 160/80mm of hg.

      p.r:- 82 bpm

      CVS:- S1,S2 heard.

      R.S:- normal vesicular breath sounds heard.

       CNS:- cranial nerves intact. 

A -  acute kidney injury with DM, HTN.

P - 

Lasix INJ (40mg) i.v /bd.

T.nicardia (10mg) po/tid.

T.nodosis (500mg) po/tid.

T.mexl (50mg) po/od.

Grbs monitoring for every 6hrs.

HAI INJ. Accor to grbs.

Bio-d3 (cap) po/od.

T.shelcal (500mg) po/od.

T. PANTOP (40mg), od.