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A 46 old male patient came to OPD with cheif complaint of shortness of breath ,profuse sweating, Generalized weakness and swelling in upper and lower limbs
History of present illness:
Patient was asymptomatic 3 months back then patient developed shortness of breath since 1 month and generalized weakness , facial puffiness and upper and lower limb edema .
Then patient dignosed as diabetic nephropathy with history of diabetes and hypertension . Patient undergone 4 sessions of hemodialysis.
Past history:
Patient is not a known case of epilepsy, tuberculosis and asthma.
Personal history
Sleep : reduced
Bowel and bladder movements :Normal.
Appatite:loss of appetite
Micturition: decreased
Habits: Alcoholic and smoker.
Drug history:
.On medication like on
.Glidazide-morning
Viglibose-afternoon
Nicardia-20mg OD+ 10mg(night)
Family history:
There is no history
of similar complaints in family members.
General Examinations:.
The patient is conscious, coherant and cooperative. He is well oriented to time , place and person . Moderately built and nourished
Anemia present
Pallor is present
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy.
Eodema is seen that too piting type
Vitals--PR 90bpm
PR 90bpm
RR 17cpm
BP 110/70mmHg
SpO2 98% in room
airTemperature febrile.
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation:
JVP - normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
No palpable mass or free fluid
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal.
Investigations:
Provisional Diagnosis:
Diabetic Nephropathy ,CKD on MHD and also K/C/O Diabetes mellitus 2 with Hypertension
Treatment :
Tab Lasix Po /BD
Tab gliclaside PO/BD 50mg
Tab Voglibose 0.2 mg PO/BD
Tab metxl 25 mg poOD
Tab Nicardia 10mg Po BD
Tab Orofer XT po/BD
Tab PAN 40mg PO/BD
Tab Nudosis 50mg PO/BD
INJ Erythropoietin (weekly)
Tab Augmentin
Tab Azithromycin
Syp Benedryl 5ml PO/ BD
Tab Levocitrizine 5mg PO /TD
Tab PCM 650mg PO/SOS
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