53 year old female patient c/c B/l loin pain

53yrs old female patient presented with CHIEF COMPLIANTS of B/L Loin pain since 6days and decreased urine output since 4 days and SOB (Grade 2-3) since 3days



HOPI

Patient was apparently asymptomatic 6days back then she had B/L Loin pain since 6days(it started in lower back midline and radiated to groin region) and decresed urine output since 4 days and then she had SOB(Grade 2-3) since 3 days.

Daily routine:

She wakes up at 7am and does her daily chores and makes breakfast and have their breakfast at around 9am and takes rest for some time and then she used to do work like washing utensils and cleaning the work but when she was diagnosed with hypertension she stoped her work she just cooks and take rest for 2-3 hrs in the afternoon.

PAST HISTORY

she had similar complaints of loin pain 2months back for which she had given anti biotics and told to drink more water by local practioner in miryalaguda

k/c/o Type 2 DM from 12 years and on OHA recently shifted to insulin injections

and HTN from 7 years and on anti hypertensives

Not a k/c/o TB,EPILEPSY, ASTHMA.

No Previous surgeries

TREATMENT HISTORY

OHA recently shifted to insulin injections for DM,anti hypertensives for HTN

FAMILY HISTORY

Not significant

PERSONAL HISTORY

Mixed Diet 

Appetite Normal

Bowel movements are Regular

Decreased urine output

Sleep Adequate

No Addictions 

No known allergies.

GENERAL EXAMINATION



Patient was conscious well oriented to time,place , person.Well built and moderately nourished.

PALLOR IS PRESENT

CYANOSIS

NO ICTERUS

NO CLUBBING





NO GENERALISED LYMPHADENOPATHY

NO PEDAL EDEMA

VITALS::

TEMP AFEBRILE

PR 70bpm

RR 12cpm

BP 120/80mmHg

SYSTEMIC EXAMINATION

1.CVS

**S1 ,S2 heard

**No murmurs.

2.Respiratory system

**Dyspnoea- No

**Wheeze -No

**Position of trachea-Central

**Breath sounds-vesicular

3.ABDOMEN

**Shape of abdomen-scaphoid

**Tenderness-No

** Palpable mass-No

** Liver- Not palpable

**Spleen - Not palpable

**Bowel sounds - No





4.CNS 

* No abnormalities detected

Provisional diagnosis :AKI on CKD,2° to diabetic nephropathy 

INVESTIGATIONS::

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