Case history 3

 5th September 2021

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A 45 year old female came to casualty  in altered sensorium.

Present History : 

Patient was apparently asymptomatic before 20 yrs then she was diagnosed with  diabetic mellitus .

In the month of April - patient went to the hospital with chief compliant of swelling of feet, shortness of breath since 1 month and increased micturition during night.

In the month of May - patient had decreased appetite and easy fatiguability.

In the month of July - patient had fever with chills, swelling over the AV fistula associated with pain and tingling sensation.

In the month of August - patient had nausea and vomiting.

Past History : 

Patient is a known case of diabetes since 20 years and hypertension since 5 months.

And  asthma  since 20 years.

No history of CAD, tuberculosis, epilepsy .

Personal History :

Diet - mixed 

Appetite - lost 

Bowel and bladder movements- irregular 

Addictions - non alcoholic and non smoker 

Family history : 

No history of similar complaints in the family .

GENERAL EXAMINATION : 

Pallor - present 

Cyanosis - absent 

Icterus - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema - bilateral pitting type edema present 

VITALS : 

Temperature - Afebrile 

Respiratory rate - 24 cpm 

Pulse rate - 90 bpm 

SpO2 - 99% 

SYSTEMIC EXAMINATION : 

CVS : 

No thrills 

S1 ,S2 heard 

No cardiac murmurs 

Respiratory system 

No dyspnea 

No wheeze 

Breath sounds - vesicular 

Position of trachea -  central 

Abdomen 

Shape of abdomen - obese 

No tenderness 

No palpable mass 

Hernial orifices - normal 

No bruits 

CNS : 

Level of consciousness - irritable 

No neck stiffness 

INVESTIGATIONS : 

                 ECG 

Provisional diagnosis : Patient is known case of diabetes mellitus type -2 and hypertension.

CKD on maintenance hemodialysis.

Treatment : 

Inj NaHCo3  

Inj PANTOP 

Inj Zofer 

Inj optineuron

Inj HAI