A 60 yr old man ,driver by occupation diagnosed with diabetes 15 yrs back came with
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
GRBS :237 mg


Systemic examinationCVS : S1S2 +
RS : BAE +
Per abdomen : soft ,non tender
CNS: NAD
INVESTIGATIONS
ECG
MRI IMAGES




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

Popular posts from this blog

A case of 48 yr old male with UNCONTROLLED SUGARs n FEVER UNDER EVALUATION

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box A 48 yr old male  welder by occupation came with complaints of  FEVER since 4 days C/O chest pain since 5 days  Pt was apparently asympyomatic 4 days back then developed fever ,intermittent,associated with chills and rigors ,no burning micturition Chest pain on n off ,non radiating Pt was k/C/o DM since 4 yrs on inj Mixtard Pt was havi g complaints of weight loss, fever 4 yrs ago and diagnosed with pulmonary kochs and used ATT for 6 months After using ATT for 2 months pt had 1 episod
Read more

medicine case study

Present condition  The patient..  falls frequently to the left. Her left foot and hand started to worsen. She has  Rashes on face around 2 to 4 episodes per year . Developed swelling, hair loss and fatigue. She has left jaw pain radiating to the face. She has dyspnea, oliguria .develops swelling when ingesting most of the foods, or smoke.Finds herself to be slim morning and appears to be a pregnant in the noon.  Develops weakness on exertion. Craves for salt . Ingests 2-4 tbs of salt when she feels sick.  EVALUATION OF THE SYMPTOMS: Swelling and breathing difficulties: -swelling which is the main complaint can be due to her having g6pd deficiency which causes hemolysis n in turn causes congestive heart failure nd shortness of breath. She might have developed kidney failure leading to the swelling due to the oxidative stress...g6pd is an enzyme that catalyzes the rate limiting step in penrose phosphate pathway n produces NADPH which in turn produces glutathione that prevents oxidative s
Read more

A 70 YR OLD MALE WITH LIVER ABSCESS

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box patient came with complaints pain abdomen since 2 days Fever since 10 days And dribbling of urine since 10 days Patient was apparently asymptomatic 3 yrs back then he developed low grade fever for days following swelling for scrotum for 3 days insidious and then he went to surgeon ,for which intervention was done later he developed 1 week back insidious and low grade for initial 5 days for which he went local RMP ,fever was not relieved and fever increased from past days which is hig
Read more