CASES IN GENERAL MEDICINE
A 57 yr male agriculture by occupation came to follow up for dialysis.
CHIEF COMPLAINTS:-
*Abdominal distension
*Burning micturition since 3 days
*Vomiting since 3 days
HISTORY OF PRESENT ILLNESS:-
*Patient was apparently asymptomatic 5 years back, had complaints of polyuria and polydipsia.
*1 year back had H/O of left Hemiplegia.
*10 days back he had H/O of bilateral pedal edema, SOB and abdominal distension.
PAST HISTORY :-
*k/c/o HTN, DM-2 since 5 years
*Had CVA 1 year back
*He had 2 dialysis before coming here
TREATMENT HISTORY :-
*He was on medication for DM and HTN since 5 years
*He was on antiplatelet and physiotherapy for Left Hemiplegia
PERSONAL HISTORY :-
*He is a vegetarian, stopped Non-veg 1 year back
*Bowel movement is Regular
*No H/O of alcohol and smoking but occasionally he used to drink Toddy
FAMILY HISTORY:-
*No familial History
GENERAL EXAMINATION:-
*Patient was in a conscious state
*Pallor-Mild
*Icterus present
*No cyanosis and clubbing
*No lymphadenopathy
*B/l pedal edema- pitting type
ON EXAMINATION:-
*Temperature- Afebrile
*Pulse Rate- 89bpm
*BP- 180/110 mmHg
*SPO2-100%
SYSTEMIC EXAMINATION:-
CVS:-
*S1,S2-+
*No cardiac murmur
RESPIRATORY SYSTEM:-
*No Dyspnea
ABDOMEN:-
*Obese
*No Tenderness
*Bowel sounds- +
CnS:-
*Conscious
*Speech is normal
*Motor system- Power R L
5/5 4/5
5/5 4/5
*Tone- Normal
INVESTIGATIONS:-
Comments
Post a Comment