Case history- 5

" This is an online E- log book to discuss our patient's de- identified health data shared informed after taking his/ her guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E- log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."

A 46 year old male patient came to OPD with chief complaints of shortness of breath since 5 days, increased sweating and weakness,  pedal edema since 1 month and facial puffiness since 10 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 month back and then he noticed swelling of limb, facial puffiness since 10 days , shortness of breath since 5 days , profuse sweating and generalised weakness.
No history of decreased urine output.

PAST HISTORY:

Patient is a known case of diabetic mellitus since 11 years and hypertension  since 3 years.

No history of  CAD, asthma, TB, epilepsy, thyroid disorders. 

No history of surgeries in the past.

PERSONAL HISTORY:

Appetite: lost

Diet: mixed

Sleep: adequate 

Bowel and bladder movements: regular

Micturition: normal

Addictions: Alcohol consumption- occasionally
 
FAMILY  HISTORY:

There is no history of similar complaints in the family.

TREATMENT HISTORY:
 
Patient was on this  regular medication 

         For diabetes -  Tab.Voglibose 0.2 mg BD
                                    Tab.Glidazide 50 mg BD

         For hypertension- Tab.Met- XL 25mg OD
                                            Tab. Amlo 10mg OD

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time, place and person. 

 There is no signs of icterus, cyanosis, clubbing  and generalised lymphadenopathy. 

There is pallor and pedal edema of pitting type.


VITALS:

Temperature:  afebrile 

Blood pressure:  140/ 90 mm Hg

Respiratory rate: 24 / min

Spo2: 98% at room temperature 

Pulse rate: 96 beats/ min

GRBS: 104 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills

S1 and S2 sounds are heard

No cardiac murmurs

RESPIRATORY SYSTEM:

No dyspnoea

No wheezing sounds

Position of trachea- central 

Breath sounds- vesicular

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver- not palpable 

Spleen- not palpable 

Bowel sounds-  no

CENTRAL NERVOUS SYSTEM:

Level of consciousness: alert

Speech: normal 

Signs of meningeal irritation

              Neck stiffness- no

Cranial nerves- normal

Motor system- normal 

Sensory system- normal   

INVESTIGATIONS:

                    HAEMOGLOBIN

            COMPLETE URINE EXAMINATION


                          RFT


                 ANTI HCV ANTIBODIES - RAPID

               BLOOD SUGAR- RANDOM

                      FERRITIN



                 HEMOGRAM

                  SERUM CREATININE 


                 BLOOD UREA


             SARS - COV- 2  QUALITATIVE PCR


           SEEUM ELECTROLYTES


            HBsAg- RAPID 


  DIAGNOSIS:
       
           Diabetic Nephropathy

TREATMENT:

       Tab. Lasix 40mg BD
       Tab. Glidazide 50mg BD
       Tab. Voglibose 0.2mg BD
       Tab. Met- XL 25mg OD
       Tab. Amlo 10mg OD
       Tab. Oroferx T BD
       Tab.Pan 40mg OD
       Tab.Nodosis 50mg BD
         

      

 


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