General medicine case-05
02/11/2021
Serum creatinine:2.6 mg/dl.
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A 45 year old male patient welder by occupation came to opd with cheif complaints of bilateral pedal edema since 2 years,shortness of breath since 3 years ,back pain,knee pain,since 3 years and facial puffiness since 1 year.
History of present illness:-
Patient was apparently asymptomatic 3 years back then he developed shortness of breath which was subsided when he took medication from local doctor.
He was also having facial puffiness,
bilateral pedal edema of pitting type.
He is also having back pain ,knee pain.
Past History:-
Patient is known case of diabetes since 6 years.
Patient is known case of hypertension since 6 months .
Patient had an episode of seizures 1 1/2 yrs ago (involuntary movements were in left UL and LL)A similar episode of seizures occurred only once since then.
No h/o surgeries done.
Personal history:-
Patient has normal eating habit with mixed diet.
He is an alcoholic,smoker.
He has habit of chewing pan and Zarda.
Apetite normal.
Sleep normal.
Family history:-
No significant family history.
General examination:-
Patient is conscious ,coherent ,cooperative .
Pallor present.
Pitting edema is seen.
No cyanosis,clubbing,icterus.
Vitals:
Temperature-Afebrile.
Pulse rate -82 beats/min.
Respiratory rate-20cycles/min.
BP-120/80 mm/hg.
Systemic examination:-
CVS-S1,S2 heard.
Respiratory system-No dyspnea,no wheeze.
CNS:-He is conscious.Speech is normal.No abnormalities detected.
Abdomen-Normal.
Investigations:-
Hemogram-
CUE:-
Serum potassium :4.6mmol/L
Serum electrolytes:
Sodium:-139 mEq/L
Potassium:- #3.1 mEq/L
Chloride:-101 mEq/L
Blood urea :36 mg/dl
Reticulocyte count :0.6 %
Urine Protein/Creatinine Ratio:
Spot urine protein:- 253 mg/dl
Spot urine protein:- 52.2 mg/dl
Ratio:- 4.84
Liver function Test (LFT):
Total Bilurubin :- 0.32 mg/dl
Direct Bilurubin :- 0.13 mg/dl
SGOT(AST) :-15 IU/L
SGPT(ALT) :- 12 IU/L
Alkaline phosphate:-#336 IU/L
Total proteins :- 4.5 gm/dl
Albumin :- # 2.2 gm/dl
AG ratio:- 0.97
Provisional diagnosis:-Nephrotic syndrome.
