Case history- 6
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A 55 year old female patient came to OPD with chief complaints of shortness of breath and swelling of the legs since 3 days and fever associated with chills since 1 day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 days back and then she noticed shortness of breath and pedal edema since 3 days.
She also complaints of fever associated with chills from 1 day.
Patient had history of diabetic nephropathy, 5 sessions of hemodialysis done.
PAST HISTORY:
Patient is a known case of diabetic mellitus and hypertension since 15 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: no
FAMILY HISTORY:
There is no history of similar complaints in the family.
TREATMENT HISTORY:
Patient was on regular medication for diabetes and hypertension.
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.
VITALS:
Temperature: 101.1°F
Blood pressure: 140/80 mm Hg
Respiratory rate: 24/min
Spo2: 98% at room temperature
Pulse rate: 98 beats/min
GRBS: 208 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- obese
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:
RFT
COMPLETE URINE EXAMINATION
HEMOGRAM
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