General medicine case 20 sasidharreddy

 GENERAL MEDICINE CASE


DATE OF ADMISSION - 22/06/22

CHIEF COMPLAINTS

- 45 yr old female came to OPD with chief complaints of swollen legs,leg pain,distended abdomen.

HISTORY OF PRESENT ILLNESS 

-C/O abdominal distension since 2months

- pedal edema and shortness of breath since 2months.

-k/o decreased appetite and loss of weight.

HISTORY OF PAST ILLNESS 

k/c/o DM and on INJ mixtard insulin

k/c/o hypothyroidism and on T.Thyronorm

k/c/o HTN and on T.Telma.

TREATMENT HISTORY

k/c/o DM,HTN

Not a k/c/o CAD,TB,asthma,chemo,radiation and blood transfusion.

PERSONAL HISTORY

Mixed diet

Appetite Normal

Sleep adequate

Bowel and Bladder movements regular.

FAMILY HISTORY

Not significant 

PHYSICAL EXAMINATION

Temp- afebrile

BP-130/70 mm hg

Pulse rate-98/min

Respiratory rate-22/min

Spo2-98%

GRBS-540mg%

-No signs of pallor,cyanosis,lymphadenopathy,icterus.

SYSTEMIC EXAMINATION 


CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - distended 

•No Tenderness

•No palpable mass

 -free fluid present.

-No palpable liver or spleen


CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• No finger nose incordination

•No knee heel incordination.


INVESTIGATIONS













PROVISIONAL DIAGNOSIS

Ascites evaluation with diabetic nephropathy.

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