General medicine case discussion
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NAME : Mamidi Harini
ROLL NO : 66
CASE DISCUSSION
Date of admission: 11/12/20
A 36 years old male who is a driver by occupation came with
CHIEF COMPLAINTS:
Fever since 10 days
Both lower limb swelling since 10 days
Facial puffiness since 10 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 11 years back . Then he developed fever and went to hospital. He diagnosed as Diabetes mellitus and was on oral hypoglycemic agents for 6 years and then shifted to insulin two times a day morning and night ( 15 units)
Then he was fine till 1 year back and developed decreased urine output associated generalized body edema and admitted in hospital and he was informed that he was having kidney problem. And he also diagnosed with hypertension. He was fine till 10 days back and started developing swelling and ulcer in right foot associated with fever and facial puffiness.
PERSONAL HISTORY:
Marital status: married
Occupation: driver
Appetite: decreased appetite
Diet: mixed
Bowel : regular
Micturation: abnormal
Addictions: alcoholic and smoker
PAST HISTORY :
He was presented with diabetes mellitus 10 years backhypertension 1 year back.
No history of TB , asthma
No history of blood transfusion
No history of surgeries.
FAMILY HISTORY:
No family history
GENERAL EXAMINATION:
Conscious, coherent, co-operative Moderately built, nourished.
PALLOR: PRESENT
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
EDEMA Of FOOT : PRESENT
VITALS
TEMPERATURE: 99 F
PULSE RATE:84 beats /min
RESPIRATORY RATE: 18 Cycles/min
BP:170/100mm of hg
SPO2:96% at room air
SYSTEMATIC EXAMINATION
CVS:
S1,S2 Sounds heard
No audible murmurs
Thrills:No
RESPIRATORY SYSTEM
RESPIRATORY SYSTEM:
Dyspnea is absent
Wheeze is absent
Position of trachea:central
Normal vesicular breath sounds are heard
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
Diabetic nephropathy.
