A 62 yr old male patient came to med opd with complaint of nausea and vometing, fatigability and decrease urine output.

Hi i am kunal marathe 3rd sem This is an online E logbook 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 a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs

Chief complaint -
62 year old male patient came with cheif  complaint of nausea & vomiting from last 2 days early fatigue from 10 days and pedal edema from last 2 months and decrease urine output from 15 days.

History of present illness-
 Patient was asymptomatic 2 months back then he developed pedal edema and early fatigability since 10 days . Nausea and vomiting from last 2 days and decreased urine output since 15 days

History of past illness-
Patient is having HTN from last 10 yrs and having medications for it .
He's having DM since 2 yrs .
Kidney problems is found 2 years back.

Personal history-
Normal appetite
Sleep adequate 
Bowel movement is regular
Reduced micturition 
Biddi smoking 2-3 per daybut stop last 5 years
No alcohol intake

Family history-
No significant family history

General examination-
Patient is conscious,coherent and cooperative
moderately built and well nourished
No pallor  
No icterus 
No clubbing of fingers
No cyanosis 
No Lymphadenopathy
PEDAL EDEMA PRESENT

Vital signs-
BP-120/80mmhg
Pulserate- 92 bpm
SpO2 -98%
Temprature -98.2 F 
GRBS- 102 mg/dl
 
Systemic examination-
CVS - S1 & S2 present
No thrills

Respiratory system-
No dyspnea
No wheezing
Position of treachea is central 
Breath sound - vesicular
Adventitious sound is rhonchi 

 CNS -
Conscious and coherent 
Speech is normal
Cranial nerve, motor system,sensory system intact

Investigation -
Random blood sugar
Renel function test
Hemogram 
Liver function test 
Complete urine examination
ECG

Probable diagnosis - diabetic nephropathy 


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