Diabetic Nephropathy

HISTORY COLLECTION
DEMOGRAPHIC DATA
Name : Mr. Sivaraman K
Age : 64 years
Sex : Male
Address : Mullakkal, Changaramkulam, Malappuram
Hospital No : 158967
Date of admission : 05/12/2019
Consultant : Dr T T Paul
Ward : II B
Diagnosis : Diabetic Nephropathy
Date of care started : 05/12/2019
Date of care ended : 09/12/2019
Date of discharge : 09/12/2019
CHIEF COMPLAINTS ON ADMISSION
Mr Sivaraman came to the hospital with complaints of generalized fatigue, edema,

oliguria for 2 days.
PRESENT MEDICAL HISTORY
Mr Sivaraman admitted in the ward of Westfort Hitech Hospital with complaints of

generalized fatigue, edema, oliguria for 2 days. On admission, the patient was conscious
and oriented. His vital signs were temperature-98.60C, pulse- 82 beats/minute, respiration-
20 breaths/minute and blood pressure- 170/90 mm Hg. Seen by Dr T T Paul ordered for
admission in II B. He was treated with T. Arkamin 100mcg PO TID, T. Telma 40 mg PO
OD, T. Lasix 40 mg PO BD, T. Renosave 650mg PO OD, T.Gemer 501mg PO BD.
PAST MEDICAL HISTORY
Mr Sivaraman is known case of type II diabetes mellitus for 15 years and renal
impairement that is diabetic nephropathy for 5 years
PRESENT/ PAST SURGICAL HISTORY
There is no relevant present or past surgical history.
FAMILY HISTORY
Key:
Male
Female
Patient
deceased
FAMILY MEDICAL HISTORY
Mr Sivaraman brothers have hypertension and diabetes mellitus and they are on
regular treatment. There is no history of oncological, psychiatric or communicable illness.
SOCIO ECONOMIC STATUS
Mr Sivaraman belongs to middle class family with all the facilities such as
electricity, water supply and sanitation. He maintains good relationship with friends and
neighbours.
PERSONAL HISTORY
Mr Sivaraman is vegetarian. He takes three meals per day. He is not allergic to

foods or drugs. He had disturbed sleeping pattern due to discomfort. He has oliguria but
bowel pattern is normal. He belongs to Hindu religion and follows all rituals and customs
of the community.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
General appearance : Looks anxious
Body built : Appropriate to age
Nourishment : Nourished
Posture : Erect
Gait : Coordinated
Body movements : Purposeful
Overall hygiene and grooming : Neat and tidy
Body odour : No odour
Attitude : Cooperative
Mood : Appropriate to situation
Speech : Understandable
Thought : Logical in sequence
Orientation : Oriented to time, place, person
Level of consciousness : Conscious
VITALSIGNS
Temperature : 98.60F
Pulse : 82 beats/ minute
Respiration : 20 breaths/ minute
Blood pressure : 160/80 mm Hg
Pain : 2/10 2 4 6 8 10
ANTHROPOMETRIC MEASUREMENT
Height : 176cm
Weight : 65 Kg
BMI : 65/ (1.76)2 = 20.98 kg/m2

HEAD TO FOOT EXAMINATION
HEAD
Skull
Size : Normal
Shape : Round
Symmetry : Symmetrical
Face
Look : Normal
Symmetry of facial structure : Normal, symmetrical
Symmetry of facial movements : Symmetrical
Symmetry of facial sensation : Symmetrical
Facial hair growth : Appropriate
Scalp
Cleanliness : Clean
Lesions : Absent
Infestation : Absent
Texture : Dry
Hair
Colour : greyish
Quantity : Thick
Distribution : baldness
Texture : Dry
Skin
Colour : Black
Lesions : Absent
Bruises : Absent
Temperature : Warm
Redness : Absent
Hair distribution : Normal
EYES
External eye structure
Eye position and alignment : Symmetrical
Size : Normal
Eye brows
Size : Thin
Hair distribution : Evenly distributed
Movements : Equal
Eyelids
Skin quality & texture : Skin intact
Tenderness : Present
Symmetry of eye closure : Normal
Ability to blink : 15-20 blinks/minute
Eye lashes
Distribution : Evenly distributed
Direction of curl : Straight
Lesions : Absent
Conjunctiva & sclera
Colour : Transparent
Texture : Smooth
Cornea
Texture : Transparent
Lesions : Absent
Corneal reflex : Present
Pupils & Iris

Colour : Black
Shape : Round
Reaction to light : Constricted
Reaction to accommodation : Normal
Visual field
Peripheral visual field : Intact
6 point test : Both eyes are coordinated
Visual acuity : normal 6/6
EARS
Auricle/pinna
Colour : skin colour
Symmetry : symmetrical
Position : Outer canthus of eye proportion to the upper
part
of the pinna
Texture : Mobile
Elasticity : Pinna recoiled after it is coiled
External canal
Inspection : Cerumen present
Tympanic membrane : Normal
Hearing acuity
Normal voice test : Audible
Watch tick test : Audible
Weber’s test : positive
Rinnie’s test : Positive
NOSE AND SINUSES
External nose
Inspection
Colour : Normal skin colour
Size & shape : Symmetrical & straight
Flaring : Absent
Discharge : Absent
Palpation
Tenderness : Non Tender
Mass : Absent
Displacement : Symmetrical & straight
Patency : Patent
Nasal cavity
Floor : Normal
Septum : Non deviated
Hair : Present
Bone and cartilage : Normal
Turbinates : Pink
Polyps : Absent
Sinuses
Palpation : Normal, non tender
MOUTH & PHARYNX
Lips
Outer lips
Colour : Pink
Texture : soft and moist
Contour : Symmetrical
Inner lips & buccal mucosa
Colour : uniform pink
Texture : smooth
Moisture : Moist
Teeth
Alignment : Normal
Colour : Uniform pink
Number of teeth : 30
Dental caries : Present
Gums
Colour : Pink
Texture : Moist and firm
Bleeding : Absent
Tenderness : Absent
Infection : Absent
Tongue
Colour : Pink
Texture : Moist
Tenderness : Absent
Movements : Moves freely
Frenulum : Smooth
Palates
Hard palate & soft palate
Colour : Hard palate is light pink than soft palate
Texture : Smooth
Uvula
Position : Midline of soft palate
Mobility : Raises during vocalization
Tonsils & oropharynx
Colour : Pink
Size : Not visible
Oropharynx, colour : Pink
Texture : Smooth
Gag reflex : Present
NECK
Movements : Range of motion present in all directions
Muscle strength : Able to push against the resistance
Lymph nodes : Non palpabale
Trachea : Centrally placed
Thyroid gland : Not enlarged
Jugular vein : Not distended
ANTERIOR THORAX
Inspection
Shape : Symmetrical
Rate & rhythm : Rhythmic and effortless respiration
Temperature of the skin : Normal
Palpation
Integrity : Normal
Mass : Normal
Tenderness : Absent
Tactile fremitus : Bilateral symmetry
Percussion
Sound : Resonance over the lung field
Auscultation
Respiratory sound : Bronchial, bronchovesicular, vesicular sound heard
POSTERIOR THORAX
Inspection
Shape : AP diameter ratio 1:2
Spinal alignment : vertically alignment
Thoracic expansion : Equal in both sides
Skin quality & texture : Elastic & smooth
Palpation
Skin temperature : Normal
Tenderness : Absent
Lesions : Absent
Thoracic exertion : Symmetrical
Tactile fremitus : Bilateral symmetry of vocal fremitus
Percussion
Auscultation
Sound : Bronchial, bronchovesicular, vesicular sound heard
HEART
Inspection : Visible pulsation absent
Palpation : Lift and thrill present
Auscultation : S1 S2 sound heard
ABDOMEN
Inspection
Shape : Symmetrical
Distention : Present
Umbilicus : Normal
Lesions : Absent
Auscultation
Bowel sounds : Normal
Percussion
Sound : Dull sound
Palpation
Pain : Absent
Tenderness : Absent
Liver : Non palpable
BACK
Shape : Symmetrical
Spine : Normal
Curvature : Normal
Pain : Absent
GENITALIA & RECTUM
Shape : Symmetrical
Discharges : Absent
Pain : Absent
Itching : Absent
Bowel pattern : Normal
Bladder pattern : Normal
EXTREMITIES
Shape : Symmetrical
ROM : possible in all extremties
Pain : Absent
Edema : Absent
Swelling : Absent
Reflexes : Normal
INFERENCES
- The patient has fatigue, edema, and oliguria.
SYSTEMWISE EXAMINATION
URINARY SYSTEM
Inspection
Skin : Normal skin colour
Mouth : No ammonia breathe odour
Face : Generalised edema absent
Extremities : peripheral edema absent
Abdomen : Normal skin colour
Weight : 65 kg
Palpation
Right kidney : Not palpable
Urinary bladder : Not palpable
Percussion
Tenderness : Absent
Bladder : Non percussible
Pain : Absent
Auscultation
Bruit : Absent
CARDIO VASCULAR SYSTEM
Vital signs
Temperature : 98.60 F
Pulse : 82 beats/minute
Pulse
Pulse volume : Normal
Thrill : Absent
Arrhythmia : Absent
Veins
Distended neck veins : Absent
Edema : Absent
Thrombophlebitis : Absent
Homan’s sign : Negative
Skin
Temperature : Normal
Cyanosis : Absent
Colour changes : Absent
Peripheral pulses : Absent
Extremities
Clubbing of nails : Absent
Capillary filling time : 2-3 seconds
Varicose veins : Absent
Thorax and chest
Inspection
Colour : Same as skin colour
Shape : Symmetrical
Point of maximum impulse : Absent
Movement : Symmetrical
Palpation
Angle of Louis : Palpable
Pulsations : Absent
Tenderness : Absent
Masses : Absent
Percussion
Sound : Dull sound
Right sided heart boarder : Unable to distinguish
Auscultation
Heart rate : 82 beats/ minute
S1& S2 sounds
RESPIRATORY SYSTEM
Inspection
Pursed lip breathing : Present
Accessory muscle use : Present
Respiratory pattern : 24 breaths/ minute
Cyanosis : Absent
Clubbing of fingers : Absent
Abdominal paradox : outward
Palpation
Tracheal deviation : Absent
Tactile fremitus : Normal
Chest movement : Equal
Pain : Absent
Percussion
Hyper resonance : Heard over the lungs
Dullness : Heard over the heart
Auscultation
Crackles : Present
Respiratory sound : Normal
GASTRO INTESTINAL SYSTEM
Mouth
Ulcer, plaque on lips : Absent
Cheilosis : Absent
Tongue : symmetrical
Candidiasis : Absent
Glossitis : Absent
Teeth : 32 teeth present
Esophagus
Dysphagia : Absent
Haematemesis : Absent
Pyrosis : Absent
Dyspepsia : Absent
Abdomen
Distension : Absent
Ascites : Absent
Hyper resonance : heard over the stomach
Bowel sound : Normal
Organomegaly : Absent
Herniation : Absent
Rectum & Anus
Haemorrhoids : Absent
Mass : Absent
Fissures : Absent
Malena : Absent
CENTRAL NERVOUS SYSTEM
Mental Status
Orientation : Oriented to place, place, and time
Thought process : Orderly
Mood & affect : Normal
Cranial Nerves
Smell : Intact
Visual fields : Full to confrontation
Eyes : Intact
Nystagmus : Absent
Facial sensation : Normal
Gag reflex : Intact
Muscle strength : Normal
Motor system : Normal
Gait and station : Normal
Romberg test
Muscles : Normal
Sensory system : Normal
Sensation to light, touch &
position sense : Normal
stereognosis :
two point discrimination : normal
Reflex : Normal
MUSCULO SKELETAL SYSTEM

Evidence of wasting : Absent
Abnormal bulk : Absent
Spontaneous contractions : Normal
Palpation : swelling absent
Joints
Swellings : Absent
Skin changes : Absent
Adjacent structure : Normal
Deformity : Absent
Tenderness : Absent
Ligaments
Injury : Absent
Swelling : Absent
Pain : Absent
Bones
Deformities : Absent
Alignment : Symmetrical
Shapes : symmetrical
Growth Hamors : Absent
INVESTIGATIONS
S.No Investigations Patient’s value Normal value Remarks
1 Haemoglobin 11.5 g/dl 12.0- 15.5 g/ dl Decreased

2 WBC 8290cells/ L 4.5 - 11.0 × 109/L Normal
3 Platelets 2.68/L 150 - 400 × 109/L. Decreased
4 Sodium 131 mEq/L 135-145mEq/L Normal
5 Potassium 3.5 mmol/L 3.6 to 5.2 mmol/L Normal
6 Urea 62 mg/dl 7- 20 mg/dl increased
7 Creatinine 3.4 mg/dl 0.84 -1.21mg/dl Increased
8 FBS 232mg/dl 70-110 mg/dl Normal
MEDICATIONS
S.No Medications Dose Route Frequency Action
1 T. Telma 40mg PO OD Antihypertensives

2 T.Lasix 40mg PO BD Diuretics
3 T. Renosave 650mg PO OD Antioxidants
4 T. Gemer 501mg PO BD Hypoglycemics
5 T. Nodosis 500mg PO TID Antacids
6 T Arkamin 100mcg PO BD Alpha-agonist

hypotensive agents
HISTORY COLLECTION
DEMOGRAPHIC DATA
Name : Mr. Gopalakrishnan Nair. V

Age : 56 years
Sex : Male
Address : Mullakkal, Changaramkulam, Malappuram
Consultant : Dr T T Paul
Ward : II B
Mr Gopalakrishnan Nair came to the hospital with complaints of generalized

fatigue, edema, oliguria for 2 days.
Mr Gopalakrishnan Nair admitted in the ward of Westfort Hitech Hospital with

complaints of generalized fatigue, edema, oliguria for 2 days. On admission, the patient
was conscious and oriented. His vital signs were temperature-98.6 0C, pulse- 82
beats/minute, respiration- 20 breaths/minute and blood pressure- 180/100 mm Hg. Seen by
Dr T T Paul ordered for admission in II B. He was treated with T. Arkamin 100mcg PO
TID, T. Telma 40 mg PO OD, T. Lasix 40 mg PO BD, T. Renosave 650mg PO OD,
T.Gemer 501mg PO BD.
Mr Gopalakrishnan Nair is known case of type II diabetes mellitus for 12 years and
diabetic nephropathy for 4 years

FAMILY HISTORY
Key:
Male
Female
Patient
deceased
Mr Gopalakrishnan Nair elder brother have hypertension and sister has diabetes
mellitus and they are on regular treatment. There is no history of oncological, psychiatric
or communicable illness.
Mr Gopalakrishnan Nair belongs to middle class family with all the facilities such
as electricity, water supply and sanitation. He maintains good relationship with friends and
neighbours.
PERSONAL HISTORY
Mr Gopalakrishnan Nair is nonvegetarian. He takes three meals per day. He is not

allergic to foods or drugs. He had disturbed sleeping pattern due to discomfort. He has
oliguria but bowel pattern is normal. He belongs to Hindu religion and follows all rituals
and customs of the community.
GENERAL EXAMINATION
Posture : Erect
Gait : Coordinated
VITALSIGNS
Pain : 4/10 2 4 6 8 10
Height : 166cm
Weight : 64 Kg
BMI : 64/ (1.66)2 = 23.24 kg/m2

HEAD
Skull
Size : Normal
Shape : Round
Face
Look : Normal
Scalp
Cleanliness : Clean
Lesions : Absent
Texture : Dry
Hair
Colour : greyish
Quantity : Thick
Texture : Dry
Skin
Colour : Black
Lesions : Absent
Bruises : Absent
Temperature : Warm
Redness : Absent
EYES
Size : Normal
Eye brows
Size : Thin
Movements : Equal
Eyelids
Eye lashes
Lesions : Absent
Texture : Smooth
Cornea
Lesions : Absent
Pupils & Iris

Colour : Black
Shape : Round
Visual field
EARS
Auricle/pinna
part
of the pinna
Texture : Mobile
External canal
Hearing acuity
NOSE AND SINUSES
External nose
Inspection
Flaring : Absent
Discharge : Absent
Palpation
Mass : Absent
Patency : Patent
Nasal cavity
Floor : Normal
Hair : Present
Turbinates : Pink
Polyps : Absent
Sinuses
MOUTH & PHARYNX
Lips
Outer lips
Colour : Pink
Texture : smooth
Moisture : Moist
Teeth
Alignment : Normal
Gums
Colour : Pink
Bleeding : Absent
Tenderness : Absent
Infection : Absent
Tongue
Colour : Pink
Texture : Moist
Tenderness : Absent
Frenulum : Smooth
Palates
Texture : Smooth
Uvula
Colour : Pink
Size : Not visible
Texture : Smooth
NECK
ANTERIOR THORAX
Inspection
Shape : Symmetrical
Palpation
Integrity : Normal
Mass : Normal
Tenderness : Absent
Percussion
Auscultation
POSTERIOR THORAX
Inspection
Palpation
Tenderness : Absent
Lesions : Absent
Percussion
Auscultation
Sound : Bronchial, bronchovesicular, vesicular sound
heard
HEART
ABDOMEN
Inspection
Shape : Symmetrical
Umbilicus : Normal
Lesions : Absent
Auscultation
Percussion
Sound : Dull sound
Palpation
Pain : Absent
Tenderness : Absent
BACK
Shape : Symmetrical
Spine : Normal
Curvature : Normal
Pain : Absent
GENITALIA & RECTUM
Shape : Symmetrical
Discharges : Absent
Pain : Absent
Itching : Absent
EXTREMITIES
Shape : Symmetrical
Pain : Absent
Edema : Absent
Swelling : Absent
Reflexes : Normal
URINARY SYSTEM
Inspection
Weight : 64 kg
Palpation
Percussion
Tenderness : Absent
Pain : Absent
Auscultation
Bruit : Absent
Vital signs
Pulse
Thrill : Absent
Arrhythmia : Absent
Veins
Edema : Absent
Skin
Cyanosis : Absent
Extremities
Thorax and chest
Inspection
Shape : Symmetrical
Palpation
Pulsations : Absent
Tenderness : Absent
Masses : Absent
Percussion
Sound : Dull sound
Auscultation
S1& S2 sounds
RESPIRATORY SYSTEM
Inspection
Cyanosis : Absent
Palpation
Pain : Absent
Percussion
Auscultation
Crackles : Present
Mouth
Cheilosis : Absent
Glossitis : Absent
Esophagus
Dysphagia : Absent
Pyrosis : Absent
Dyspepsia : Absent
Abdomen
Distension : Absent
Ascites : Absent
Herniation : Absent
Rectum & Anus
Mass : Absent
Fissures : Absent
Malena : Absent
Mental Status
Cranial Nerves
Smell : Intact
Eyes : Intact
Nystagmus : Absent
Gag reflex : Intact
Romberg test
Muscles : Normal
stereognosis :
Reflex : Normal
Joints
Swellings : Absent
Deformity : Absent
Tenderness : Absent
Ligaments
Injury : Absent
Swelling : Absent
Pain : Absent
Bones
INVESTIGATIONS

5 Potassium 5 mmol/L 3.6 to 5.2 mmol/L Normal
7 Creatinine 3.8 mg/dl 0.84 -1.21mg/dl Increased
8 FBS 322mg/dl 70-110 mg/dl Normal
MEDICATIONS


hypotensive agents
HISTORY COLLECTION
DEMOGRAPHIC DATA
Name : Mrs. Manjula devi
Age : 58 years
Sex : Female
Address : nelliparambil, Alappad, Thrissur
Consultant : Dr Ranjith
Ward : II Floor
Mrs Manjula Devi came to the hospital with complaints of generalized fatigue,
edema, oliguria for 2 days.
Mrs Manjula Devi admitted in the ward of Westfort Hospital with complaints of
generalized fatigue, edema, oliguria for 2 days. On admission, the patient was conscious
and oriented. Her vital signs were temperature-98.60C, pulse- 82 beats/minute, respiration-
20 breaths/minute and blood pressure- 170/90 mm Hg. Seen by Dr Ranjith ordered for
admission in II B. He was treated with T. Arkamin 100mcg PO TID, T. Telma 40 mg PO
OD, T. Lasix 40 mg PO BD, T. Renosave 650mg PO OD, T.Gemer 501mg PO BD.
Mrs Manjula Devi is known case of type II diabetes mellitus for 15 years and renal
impairement that is diabetic nephropathy for 5 years
FAMILY HISTORY
Key:
Male
Female
Patient
deceased
Mrs Manjula Devi brothers have hypertension and diabetes mellitus and they are
on regular treatment. There is no history of oncological, psychiatric or communicable
illness.
Mr Manjula Devi belongs to middle class family with all the facilities such as
electricity, water supply and sanitation. She maintains good relationship with friends and
neighbours.
PERSONAL HISTORY
Mrs Manjula Devi is nonvegetarian. She takes three meals per day. She is not
allergic to foods or drugs. She had disturbed sleeping pattern due to discomfort. She has
oliguria but bowel pattern is normal. She belongs to Hindu religion and follows all rituals
and customs of the community.
GENERAL EXAMINATION
Posture : Erect
Gait : Coordinated
VITALSIGNS
Pain : 2/10 2 4 6 8 10
Height : 156cm
Weight : 54 Kg
BMI : 54/ (1.56)2 = 20.98 kg/m2

HEAD
Skull
Size : Normal
Shape : Round
Face
Look : Normal
Scalp
Cleanliness : Clean
Lesions : Absent
Texture : Dry
Hair
Colour : greyish
Quantity : Thick
Texture : Dry
Skin
Colour : Black
Lesions : Absent
Bruises : Absent
Temperature : Warm
Redness : Absent
EYES
Size : Normal
Eye brows
Size : Thin
Movements : Equal
Eyelids
Eye lashes
Lesions : Absent
Texture : Smooth
Cornea
Lesions : Absent
Pupils & Iris

Colour : Black
Shape : Round
Visual field
EARS
Auricle/pinna
part
of the pinna
Texture : Mobile
External canal
Hearing acuity
NOSE AND SINUSES
External nose
Inspection
Flaring : Absent
Discharge : Absent
Palpation
Mass : Absent
Patency : Patent
Nasal cavity
Floor : Normal
Hair : Present
Turbinates : Pink
Polyps : Absent
Sinuses
MOUTH & PHARYNX
Lips
Outer lips
Colour : Pink
Texture : smooth
Moisture : Moist
Teeth
Alignment : Normal
Gums
Colour : Pink
Bleeding : Absent
Tenderness : Absent
Infection : Absent
Tongue
Colour : Pink
Texture : Moist
Tenderness : Absent
Frenulum : Smooth
Palates
Texture : Smooth
Uvula
Colour : Pink
Size : Not visible
Texture : Smooth
NECK
ANTERIOR THORAX
Inspection
Shape : Symmetrical
Palpation
Integrity : Normal
Mass : Normal
Tenderness : Absent
Percussion
Auscultation
POSTERIOR THORAX
Inspection
Palpation
Tenderness : Absent
Lesions : Absent
Percussion
Auscultation
Sound : Bronchial, bronchovesicular, vesicular sound
heard
HEART
ABDOMEN
Inspection
Shape : Symmetrical
Umbilicus : Normal
Lesions : Absent
Auscultation
Percussion
Sound : Dull sound
Palpation
Pain : Absent
Tenderness : Absent
BACK
Shape : Symmetrical
Spine : Normal
Curvature : Normal
Pain : Absent
GENITALIA & RECTUM
Shape : Symmetrical
Discharges : Absent
Pain : Absent
Itching : Absent
EXTREMITIES
Shape : Symmetrical
Pain : Absent
Edema : Absent
Swelling : Absent
Reflexes : Normal
URINARY SYSTEM
Inspection
Weight : 54 kg
Palpation
Percussion
Tenderness : Absent
Pain : Absent
Auscultation
Bruit : Absent
Vital signs
Pulse
Thrill : Absent
Arrhythmia : Absent
Veins
Edema : Absent
Skin
Cyanosis : Absent
Extremities
Thorax and chest
Inspection
Shape : Symmetrical
Palpation
Pulsations : Absent
Tenderness : Absent
Masses : Absent
Percussion
Sound : Dull sound
Auscultation
S1& S2 sounds
RESPIRATORY SYSTEM
Inspection
Cyanosis : Absent
Palpation
Pain : Absent
Percussion
Auscultation
Crackles : Present
Mouth
Cheilosis : Absent
Glossitis : Absent
Esophagus
Dysphagia : Absent
Pyrosis : Absent
Dyspepsia : Absent
Abdomen
Distension : Absent
Ascites : Absent
Herniation : Absent
Rectum & Anus
Mass : Absent
Fissures : Absent
Malena : Absent
Mental Status
Cranial Nerves
Smell : Intact
Eyes : Intact
Nystagmus : Absent
Gag reflex : Intact
Romberg test
Muscles : Normal
stereognosis :
Reflex : Normal

Joints
Swellings : Absent
Deformity : Absent
Tenderness : Absent
Ligaments
Injury : Absent
Swelling : Absent
Pain : Absent
Bones
INVESTIGATIONS

5 Potassium 5 mmol/L 3.6 to 5.2 mmol/L Normal
7 Creatinine 4 mg/dl 0.84 -1.21mg/dl Increased
8 FBS 342mg/dl 70-110 mg/dl Increased
MEDICATIONS

hypotensive agents
CONCLUSION
Diabetic nephropathy is a serious kidney-related complication of type 1 diabetes

and type 2 diabetes mellitus. It is also called diabetic kidney disease. About 25% of people
with diabetes eventually develop kidney disease. Diabetic nephropathy affects the kidneys'
ability to do their usual work of removing waste products and extra fluid from the body.
The best way to prevent or delay diabetic nephropathy is by maintaining a healthy lifestyle
and treating the diabetes and high blood pressure. Over many years, the condition slowly
damages the kidneys' delicate filtering system. Early treatment may prevent or slow the
disease's progress and reduce the chance of complications. The kidney disease may
progress to kidney failure, also called end-stage kidney disease. Kidney failure is a life-
threatening condition. At this stage, the treatment options are dialysis or kidney
transplantation.

Diabetic Nephropathy

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Diabetic Nephropathy

Uploaded by

Copyright:

Available Formats

HISTORY COLLECTION

Name : Mr. Sivaraman K

Address : Mullakkal, Changaramkulam, Malappuram

Date of admission : 05/12/2019

Diagnosis : Diabetic Nephropathy

Date of care started : 05/12/2019

Date of care ended : 09/12/2019

Date of discharge : 09/12/2019

CHIEF COMPLAINTS ON ADMISSION

Mr Sivaraman came to the hospital with complaints of generalized fatigue, edema,

PRESENT MEDICAL HISTORY

Mr Sivaraman admitted in the ward of Westfort Hitech Hospital with complaints of

PRESENT/ PAST SURGICAL HISTORY

There is no relevant present or past surgical history.

FAMILY MEDICAL HISTORY

SOCIO ECONOMIC STATUS

Mr Sivaraman is vegetarian. He takes three meals per day. He is not allergic to

Pulse : 82 beats/ minute

Respiration : 20 breaths/ minute

Blood pressure : 160/80 mm Hg

BMI : 65/ (1.76)2 = 20.98 kg/m2

Symmetry of facial structure : Normal, symmetrical

Symmetry of facial movements : Symmetrical

Symmetry of facial sensation : Symmetrical

Facial hair growth : Appropriate

Pupils & Iris

Blood pressure : 160/80 mm Hg

MUSCULO SKELETAL SYSTEM

S.No Investigations Patient’s value Normal value Remarks

1 Haemoglobin 11.5 g/dl 12.0- 15.5 g/ dl Decreased

1 T. Telma 40mg PO OD Antihypertensives

3 T. Renosave 650mg PO OD Antioxidants

4 T. Gemer 501mg PO BD Hypoglycemics

5 T. Nodosis 500mg PO TID Antacids

6 T Arkamin 100mcg PO BD Alpha-agonist

Name : Mr. Gopalakrishnan Nair. V

Address : Mullakkal, Changaramkulam, Malappuram

Date of admission : 11/12/2019

Diagnosis : Diabetic Nephropathy

Date of care started : 11/12/2019

Date of care ended : 13/12/2019

Date of discharge : 14/12/2019

CHIEF COMPLAINTS ON ADMISSION

Mr Gopalakrishnan Nair came to the hospital with complaints of generalized

PRESENT MEDICAL HISTORY

Mr Gopalakrishnan Nair admitted in the ward of Westfort Hitech Hospital with

PAST MEDICAL HISTORY

PRESENT/ PAST SURGICAL HISTORY

FAMILY MEDICAL HISTORY

SOCIO ECONOMIC STATUS

Mr Gopalakrishnan Nair is nonvegetarian. He takes three meals per day. He is not

Pulse : 82 beats/ minute

Respiration : 20 breaths/ minute

Blood pressure : 180/100 mm Hg

BMI : 64/ (1.66)2 = 23.24 kg/m2

HEAD TO FOOT EXAMINATION

Symmetry of facial structure : Normal, symmetrical

Symmetry of facial movements : Symmetrical

Symmetry of facial sensation : Symmetrical

Facial hair growth : Appropriate

Pupils & Iris

Blood pressure : 180/100 mm Hg

1 Haemoglobin 12.0 g/dl 12.0- 15.5 g/ dl Decreased