Case history- 5

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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