General medicine case discussion

 CHIEF COMPLAINTS:-

A 60 year old patient came to the OPD with complaints of pedal edema in both the legs since 2 years and burning micturition. 


HISTORY OF PRESENT ILLNESS:-

The patient was apparently asymptomatic 2 years ago after which he developed pedal edema on both his legs. The patient also complained of back ache .The patient complained of pain in his legs while walking and difficulty in standing up due to weakness. The patient also complained of breathlessness while walking . The patient complained of burning micturition since 2 months.No history of fever.


PAST HISTORY:-

The patient is a known diabetic since 10 years. The patient reported of having ear deafness since 6 years. The patient visited a government hospital 5-6 months ago where he was diagnosed with kidney failure and was put on dialysis. The patient was diagnosed with hypertension 3 months ago

No H/O of TB, epilepsy , asthma 


FAMILY HISTORY:- 

No significant family history .


PERSONAL HISTORY :-

Diet- vegetarian 

Appetite-decreased since 4 days 

Bowel and bladder movements -urine flow in a drip like manner and burning sensation .

Sleep - adequate


Examination

The patient was conscious , coherent and moderately built

No clubbing of fingers

No cyanosis 

No icterus 

No pallor

No lymphadenopathy 

Oedema-Present in feet

Vitals- Temperature-98.6

            Pulse rate-82 beats /min

            BP-16 breaths/ min

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