chief complaints of
Pedal oedema since 15 days
Sob since 5 days
Decreased urine output since 3 days
Fever since 5 days
History of presenting illness
Patient was apparently asymptomatic 15 days back ,then developed pedal oedema upto ankle ,which is pitting type,
shortness of breath since 5 days which is grade 4,
Fever since 5 days ,which is continous,associated with vomiting n cough
Vomiting of one episode which bilious n non projectile 5 days back
Cough since 5 days with sputum,which is red in colour reduced after medication
Past history
He had a history of giddiness for which he went to hospital and
Diagnosed with Diabetes since 15 yrs
Had history of TB 15 yrs back ,which is treated with medication
Diagnosed with HTN 2 yrs back
Not known case of asthma,cardiovascular disorder n thyroid disorders
PERSONAL HISTORY
Alcoholic since 30 yrs
Family hisotry
Not significant
General examination
Patient was coherent,conscious,coperative
Mild -pallor ,No cyanosis,clubbing,lympadenopathy
Pedal odema since 15 days
VITALS
Temp 99.6F
Bp 140 /80 mm Hg
PR 85 bpm
RR 26 cpm
RS : BAE +
Per abdomen : soft ,non tender
CNS: NAD
INVESTIGATIONS
Provisional diagnosis
Diagnosed with Diabetic nephropathy .
TREATMENT
D ward 9/2/22
http://jyothi97.blogspot.com/2022/02/blog-post_2.html
Day 7
9/2/22
S :
Shortness of breath increased
Decreased urine output
Burning micturition since yesterday afternoon
O :
O/E
Pt is conscious, cooperative, oriented,
Pupil - normal size, pupillary reflex abesnt in both eyes
Temp 98.4 F
BP 140/90 mm Hg
PR 95 bpm
RR 26
CVS: S1, S2 +
No murmurs
RS:
BAE +
Trachea position-central.
Bilateral crepts at infra axillary area
P/A:
Soft, non tender
DISTENDED
Bowel sounds heard .
CNS:
Pt is conscious, orientation +
Slurring of speech+
Memory is good
Motor system
Tone - Rt Lt
U/L N N
L/L N N
Power
U/L 5/5 _ 4/5
L/L 5/5 _ 4/5
Reflex
Biceps 2+ 3+
Triceps 2+ 3+
Supinator 2+ 3+
Knee 2+ 3+
Ankle 2+ 3+
Plantar dorsiflexion
A
Provisional diagnosis : ACUTE infarcts in right corona radiata,
LEFT SIDED HEMIPARESIS
DIABETIC NEPHROPATHY
P
Treatment :
Physiotherapy of left upper and lower limb
1)Tab. Ecospirin 150 mg po OD
2)Tab.Clopidogrel 75mg po OD
3)salt restriction <2.4 GM/day
4) fluid restriction < 1 lit / day
5)Tab lasix 40 mg Po/TID
