Ascites and diabetic nephropathy General medicine case 24-06-22

 GENERAL MEDICINE CASE (24-06-22)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 5th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

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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