General medicine case discussion

January 3, 2023
 Hi i am Sumanth Reddy 3rd sem This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent.

Chief complaint 
62 year old male patient come with  complaint of nausea, vomiting from last 2 days early fatigue from last 1 week and pedal edema from last 2 months
History of present illness
A patient is asymptomatic 2 months back then he developed pedal edema and easy fatigability since 10 days . Nausea and vomiting from last 2 days and decreased urine output since 15 days 
History of past illness
Patient is diabetic since 4 yrs and hypertensive since 10 years .
He is on medication since it diagnosed
Kidney problems is found 2 years back
Personal history
Normal appetite
Sleep adequate 
Bowel movement is regular
Reduced micturition 
Biddi smoking 2-3 per daybut stop last 5 years
No alcohol intake
Family history
No significant family history
General examination

Patient is conscious,coherent and cooperative

moderately built and well nourished

No pallor  

No icterus 

No clubbing of fingers

No cyanosis 

No Lymphadenopathy

Pedal edema present 


Vital sign 

BP-120/80mmhg

Pulserate- 92 bpm

SpO2 -98%

Temprature -98.2 F 

GRBS- 102 mg/dl 

Systemic examination

CVS 

Cardiac sound S1 and S2 present 

No thrills 

Respiratory system

No dyspnea

No wheezing

Position of treachea is central 

Breath sound - vesicular

Adventitious sound is rhonchi 

 CNS 

Conscious and coherent 

Speech is normal

Cranial nerve, motor system,sensory system intact

Investigation 

Random blood sugar

Renel function test

Hemogram 

Liver function test 

Complete urine examination

ECG 






CLINICAL DIAGNOSIS

Diabetic nephropathy



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