GM FINAL SHORT CASE

Feb 08,2022.

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 A 60 year old male driver by occupation came to the OPD with chief complaints of 

1) bilateral pedal edema since 15days 

2) decreased urine output since 3days 

3) sob since 5 days 

4) fever since 5 days.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 15 days back he then developed pedal edema extending upto ankle which is of pitting type , shortness of breath since 5 days & fever since 5 days which is continuous and associated with vomitings( food particles as content) and cough.

Cough since 5 days with sputum,which is red in colour reduced after medication.

3 days ago when patient was undergoing dialysis he developed cerebro vascular attack.

PAST HISTORY:-

He had a history of  giddiness 15 yrs back and then went to the hospital and was diagnosed as Diabetes.

He was on ir regular medication since 6 yrs because of which he lost his eyesight( Right eye complete loss of vision,left eye blurred vision) and discontinued his driving since 10 years.

He also had h/o of TB 15 yrs back - treated with medication

Known case of hypertension since 2 yrs.

No history of asthma,cardiovascular disorder ,thyroid disorder,cancer .

PERSONAL HISTORY:-

Diet:- mixed

Sleep:- adequate

Appetite:- normal

Bowel & bladder movements :- normal 

Addictions: Aloholic :- since 30 yrs; but stopped 4 yrs ago.

FAMILY HISTORY:-

No known relevant family  history.

DRUG HISTORY:-

Is on medication for diabetes and hypertension.

Took anti tubercular drugs.

GENERAL EXAMINATION:-

Patient was conscious,coherent , unco- operative

Mild - pallor 

No cyanosis 

No clubbing

No lymphadenopathy 

Appearance - obese

VITALS:-

Temperature:-99.6 F

Blood pressure:-.140/80 mm Hg

Respiratory rate:-26cpm

Pulse rate:-85 bpm

GRBS:- 237 mg 

GENERAL EXAMINATION : 

CVS EXAMINATION:-

S1, S2+no murmurs

RESPIRATORY SYSTEM:-

   

BAE+

PER ABDOMEN:-

Soft,non tender.

CNS EXAMINATION:-

slurred speech.

INVESTIGATIONS:-

ECG:-

Clinical images : 

FINAL DIAGNOSIS:-

Diabetic nephropathy

TREATMENT:-