Case-7
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A 55 yr old male patient presented to the opd with the chief complaints of generalized body swellings,sob, decreased urine output, body pains since 5 days.
History of present illnes: patient was apparently normal 5 days back then he developed generalized body swelling shortness of breath body pains and decreased urine output.
Past history: patient is a known case of diabetes since 8 yrs and hypertension since 5 yrs.both are uncontrolled. patient had a thorn prick on his left leg . He negelected it so the infection spread upwards upto the knee( gangrene was noticed). So the left leg was amputated ( below knee amputation).
Personal history : patient follows a mixed diest.loss of appattite. Normal sleep cycles.decreaded micturition .regular bowel movements.patient is an alcoholic since 20 yrs(90ml) per day.he also had a habit of smoking beedi ( 1 pack) and also cigarette.
Daily routine : before the amputation he used to go to the work but since 1 yr i.e after the amputation he stopped going to work and stayed at home. Wakes up 9 in the morning has breakfast then lunch around 1.had dinner at 8 and goes to bed by 9.
Family history: no relavent family history.
Drug history: telmisartan 40 mg for hypertension, glimiperide 2 mg for diabetes.
Systemic examination:
Cvs: bilaterally symmetric chest wall .no precordial bulge .no thrills and no murmurs. s1 and s2 heard
Respiratory system: shortness of breath, dyspnoea ,wheeze
Position of trachea- central, no adventious sounds heard
CNS: patient is normal and concious .reflexs are normal.
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