GM CASE-3

Name : A.Anusri
Roll no :10
Introduction:
A 47yr old female patient house wife  residing in narketpally came with complaints of adbominal distension, pedal oedema and shortness of breath
Chief complaints:
Abdominal distension since 2 months
Pedal edema since 2 months
Shortness of breath since 2 months
History of present illness:
She had abdominal distension and pedal edema since 2 months. She went to various local hospitals in nalgonda. She was diagnosed with hypertension and hypothyroidism after the necessary tests. She also used medication given by them. Pedal edema was subsided but not abdominal distention. So she came to KIMS for the treatment. She came to OPD 10 days back and she was given treatment for 1 week. Then she was admitted on 22/6/22 for further treatment.
History of past illness:
She is a k/c/o hypertension(since 2 months) , Diabetes mellitus(since 6 years) , thyroid (since 2months), diabetic nephropathy
No H/O surgeries in the past
Personal history:
Married
Appetite: normal
Diet: mixed
Bowel movements: regular
Micturition : normal
No addictions
Family history:
Her mother is a diabetic patient
General examination:
Pallor - yes
No icterus
No clubbing 
No cyanosis
No lymphadenopathy
No pedal edema
No dehydration
Temperature- afebrile
Pulse rate- 98/ min
Respiratory rate: 22 /min
BP - 110/70 mmHg
Spo2 98%
GRBS 540mg/dl
Systemic examination:
CVS:
No thrills 
No murmurs
S1 S2 present
Respiratory system:
No dysnopea
No wheeze
Position of trachea is central
Hernial orifice - normal
Free fluid - yes
Bruits - no
Liver not palpable
Spleen not palpable
Bowel sounds - yes
CNS:
Level of consciousness - conscious
Speech - normal
Sign of meningeal irritation
   a) neck stiffness- no
    b) kernigs sign- no
Cranial nerves- normal
motor system - normal
sensory system -normal
Glassgow scale - normal
Reflexes:
      Biceps. Triceps. Supinator knee ankle
R.     +             +                +            +        +
L.      +             +                +            +         +

Cerebral signs:
Finger nose in co ordination- no
Knee heel incordination - no
Provisional Diagnosis:
Ascites with diabetic nephropathy
Treatment:
Inj HAI s/c acc to GRBS
Tab T6LMA 40mg PO /OD
GRBS monitoring 6 th hrly
Inj LASIX 40 mg iv/bd
Tab OROFOR XT bd
Tab NOPOSIS 500 mg PO/ BD
Tab SHGLCA-L-D3 PO/BD
Inj. ERYTHROPOETIN 4000IU s/c once weekly
Investigations:
Na+ 130
K+ 4.0
Cl- 10.1
Ca+2  8.3
Po4-2 4.8
CBP
Hb 9.5
TLC 7500
Platelets 3.53
CUE
albumin 4+
Sugars 4+
Pus cells 4-6
Epithelial cells 2-4
Blood urea: 99
Serum creatinine: 2.7
LFT:
TB 0.5
DB 0.22
AST 18
ALT 14
ALP 94
TP 4.9
Albumin2.4
USG REPORT:

 

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