Roll - 17
Batch - 2019
- tightness of abdomen since 1 week
- shortness of breath since 1 week
- decreased urine output since 15 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15 days ago when he developed high grade fever which was associated with chills and rigor.
A/w decreased urine output and buring micturition with hesitancy.
Patient also complaints of blotting in abdomen which is not associated with food intake, belching and regurgitation but a/w shortness of breath.
He developed Anasarca.
B/l pedal edema present.
Not a/w pain in abdomen, nausea, vomiting and loose stool.
Not a/w chest pain, palpitations and cough.
History of past illness
K/c/o diabetes mellitus type 2 since 10 years a/w diabetic foot since 1 month.
Gangrene of big toe was present 2 years ago.
Diagnosed with anemia 1 year back.
Not a k/c/o HTN, asthma, epilepsy, CAD, thyroid disorder.
Treatment history
He took oral antidiabetic tablets but shifted to insulin inj one year ago.
Amputation of right big toe 2 years ago.
He was admitted to other hospital for decreased urine output for which iv fluid was given.
FAMILY HISTORY
No history of similar complaints among family members.
PERSONAL HISTORY
Appetite- normal
Diet - mixed
Sleep - adequate
bowel - normal
bladder - hesitancy and burning micturition
No drug allergy and addictions.
General Examination-
Patient is moderately built and nourished.
He is conscious, cooperative,comfortable.
No signs of pallor ,cyanosis ,icterus ,koilonychia , lymphadenopathy ,edema .
Vitals :
Patient is afebrile .
Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial delay.
BP - 110/70 mmhg ,measured in supine position in both arms .
Respiratory rate -22 breaths / min
Systemic Examination
CVS -
S1 and S2 heard
No thrills
No cardiac murmur
No focal deficits
RESPIRATORY SYSTEM:
NVBS
BAE+
No cripts
PER ABDOMEN:-
Blotting present
shape of abdomen is Scaphoid
Tenderness not seen
No palpable mass
Bowel sounds are heard
Liver and spleen are not palpable
No free fluid
No bruits
Normal hernial orifices
CNS:-
Patient is conscious.
Speech is normal.
No signs of meningeal irritation.
Reflexes are normal
Investigation
Haemogram, RFT, LFT
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