GM FINAL SHORT CASE
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A 60 year old male driver by occupation came to the OPD with chief complaints of
1) bilateral pedal edema since 15days
2) decreased urine output since 3days
3) sob since 5 days
4) fever since 5 days.
HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 15 days back he then developed pedal edema extending upto ankle which is of pitting type , shortness of breath since 5 days & fever since 5 days which is continuous and associated with vomitings( food particles as content) and cough.
Cough since 5 days with sputum,which is red in colour reduced after medication.
3 days ago when patient was undergoing dialysis he developed cerebro vascular attack.
PAST HISTORY:-
He had a history of giddiness 15 yrs back and then went to the hospital and was diagnosed as Diabetes.
He was on ir regular medication since 6 yrs because of which he lost his eyesight( Right eye complete loss of vision,left eye blurred vision) and discontinued his driving since 10 years.
He also had h/o of TB 15 yrs back - treated with medication
Known case of hypertension since 2 yrs.
No history of asthma,cardiovascular disorder ,thyroid disorder,cancer .
PERSONAL HISTORY:-
FAMILY HISTORY:-
No known relevant family history.
DRUG HISTORY:-
GENERAL EXAMINATION:-
Mild - pallor
No cyanosis
No clubbing
No lymphadenopathy
Appearance - obese
VITALS:-
CVS EXAMINATION:-
RESPIRATORY SYSTEM:-
PER ABDOMEN:-
CNS EXAMINATION:-
INVESTIGATIONS:-
ECG:-
FINAL DIAGNOSIS:-
Diabetic nephropathy
TREATMENT:-
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