General medicine case history 5
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A 57 year old male who is salesman by occupation presented to opd with chief complaints of b/L pedal edema since 15 days,itching (generalized)and loss of appetite.
Date of admission : 30/12/2021
History of present illness :
Patient was apparently asymptomatic 3 months back and developed dizziness and pedal edema for left leg 2 months back then he visited local hospital there he diagnosed for DM and hypertension and underwent vascular surgery(thrombosis of popliteal artery) of left leg.Then he developed B/L pedal edema, generalized itching since 1month and visited our hospital.
History of past illness :
No similar complaints in the past
Patient is k/c/o DM, hypertension since 2 months and asthma since 5 years.
Patient is not a k/c/o tuberculosis, epilepsy.
PERSONAL HISTORY:
appetite : normal
Bowel : regular
Micturition: normal
Diet : vegetarian.
Sleep : adequate
FAMILY HISTORY:
no similar complaints in the family
GENERAL EXAMINATION:
patient is conscious , coherent, cooperative
No Pallor
No Cyanosis
No Icterus
No lymphadenopathy
Pedal edema - present
No Malnutrition
No Clubbing
BP : 150/100 mmHg
Pulse rate : 90 beats per min
Respiratory rate : 20 cycles/min
Temperature : Afebrile
Spo2 at room temperature : 94%
Systemic examination:
CNS :
Patient is Conscious
Speech normal
CVS :
S1 , S2 sounds heard
No murmers
RESPIRATORY SYSTEM:
Position of trachea- central
Breath sounds: vesicular
PER ABDOMEN:
No tenderness, palpable mass
Liver and spleen not palpable
PROVISIONAL DIAGNOSIS :
Chronic kidney disease (diabetic nephropathy)on MHD
Investigations
30/12/2021
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