PERIPHERAL NEUROPATHY (SENSORY &MOTOR) DIABETES MELLITUS SINCE 30 YEARS HYPERTENSION SINCE 30 YEARS CHRONIC KIDNEY DISEASE SINCE 13 YEARS BENIGN PROSTATIC HYPERPLASIA

 Case History and Clinical Findings

C/O GIDDINESS SINCE 15 DAYS

HOPI-

PATIENT WS APPARENTLY ASYMPTOMATIC 15DAYS AGO THEN DEVELOPED EPISODES OF GIDDINESS A/W BLURRING OF VISION A/W SWEATING RELIEVED AFTER TAKING FOOD DAILY ONE EPISODE

H/O CHEST PAIN SINCE 4DAYS PRICKING TYPE ON AND OFF ,NO PRECIPITATING FACTORS

H/O TINGLING AND NUMBNESS OF LOWER LIMBS SINCE 10 YEARS EXTENDING FROM TIP OF TOES TO SHIN OF TIBIA

H/O BURNING SENSATION OF FEET SINCE 5 YEARS

H/O LOOSE STOOLS FOR 1 DAY WHICH WAS ONE WEEK AGO AND SUBSIDED ON MEDICATION FOLLOWED BY PAIN ABDOMEN IN UMBLICAL REGION SINCE THEN

NO H/O LOSS OF APPETITE SINCE 1 WEEK

NO H/O POLYURIA,POLYDIPSIA

NO H/O PALPITATIONS ,SOB

NO H/O HYPOGLYCEMIC EVENT AT NIGHT


NO H/O DECREASED URINE OUTPUT ,BURNING MICTURITION

NO H/O FEVER, PEDAL EDEMA ,FACIAL PUFFINESS

PAST H/O-

K/C/O HTN SINCE 30YRS AND ON T.TELMA AM 40/5

K/C/O DM SINCE 30 YRS ON INJ MIXTARD 20U(BBF)-X-15U(BBF)

K/C/O CKD SINCE 13 YEARS

ON EXAMINATION

PT IS CONSCIOUS, COHERENT,COOPERATIVE

TEMP-AFEBRILE

PULSE RATE 80 BPM

BP 110/80 MMHG

CVS-S1 S2 HEARD NO MURMURS

RS- BAE PRESENT NVB

P/A-SOFT,NON TENDER

OPHTHALMOLOGY REFERRAL I/V/O -DIABETIC RETINOPATHY

IMPRESSION -NORMAL FUNDUS STUDY

PROVISIONAL DIAGNOSIS 


PERIPHERAL NEUROPATHY (SENSORY &MOTOR)

DIABETES MELLITUS SINCE 30 YEARS

HYPERTENSION SINCE 30 YEARS

CHRONIC KIDNEY DISEASE SINCE 13 YEARS

BENIGN PROSTATIC HYPERPLAS


Investigation

NameValueRangeNameValueRangeRFT 04-05-2024 04:15:PM UREA37 mg/dl50-17 mg/dlCREATININE2.6 mg/dl1.3-0.8 mg/dlURIC ACID6.7 mmol/L7.2-3.5 mmol/LCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.7 mg/dl4.5-2.5 mg/dlSODIUM137 mmol/L145-136 mmol/LPOTASSIUM4.6 mmol/L.5.1-3.5 mmol/L.CHLORIDE102 mmol/L98-107 mmol/LLIVER FUNCTION TEST (LFT) 04-05-2024 04:15:PM Total Bilurubin0.56 mg/dl1-0 mg/dlDirect Bilurubin0.20 mg/dl0.2-0.0 mg/dlSGOT(AST)12 IU/L35-0 IU/LSGPT(ALT)10 IU/L45-0 IU/LALKALINE PHOSPHATASE179 IU/L119-56 IU/LTOTAL PROTEINS6.9 gm/dl8.3-6.4 gm/dlALBUMIN4.0 gm/dl4.6-3.2 gm/dlA/G RATIO1.42HBsAg-RAPID04-05-2024 04:15:PMNegative Anti HCV Antibodies - RAPID04-05-2024 04:15:PMNon Reactive COMPLETE URINE EXAMINATION (CUE) 04-05-2024 04:15:PM COLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGAR+++BILE SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilPOST LUNCH BLOOD SUGAR04-05-2024 04:17:PM196 mg/dl140-0 mg/dlABG 05-05-2024 09:12:AM PH7.33PCO229.7PO290.0HCO315.3St.HCO317.2BEB-9.1BEecf-9.4TCO231.7O2 Sat96.1O2 Count15.5

HEMOGRAM


HB-11.1

TLC-6700

PLT-2.80

RBC-3.55

HBA1C-7.1 %

FBS-70 MG/DL

PLBS-196MG/DL

SPOT UPCR-

SPOT URINE PROTEIN -6.0

SPOT URINE CREATININE 87.5

RATIO 0.06

2DECHO-

EF-65 %

IVC-0.7CM COLLAPSING

TRIVIAL TR+/AR+ ,NO MR

NO RWMA ,NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNTION ,NO PAH/PE/LV CLOT

USG ABDOMEN &PELVIS (06/5/24)

IMPRSSION -B/L GRADE 1 RPD CHAGES IN KIDNEY

B/L RENAL CORTICAL CYSTS

GRADE 1 PROSTATOMEGALY

Treatment Given(Enter only Generic Name)

T.TELMA -AM 40/5 PO/OD

T.DYTOR PLUS 10/25 PO/OD

T.PREGABALIN 75MG PO/HS

T.ECOSPORIN AV 75/10 PO HS

T.PAN 40MG PO/OD

INJ HAI S/C TID ACC TO GRBS

T.SHELCAL -XT PO/OD

TAB.NODOSIS 500MG PO/OD

Advice at Discharge

T.TELMA -AM 40/5 PO/OD CONTINUE

T.DYTOR PLUS 10/25 PO/OD X 1 MONTH
T.PREGABALIN 75MG PO/HS X 15 DAYS
T.ECOSPORIN AV 75/10 PO HS X CONTINUE
T.PAN 40MG PO/OD X 5DAYS
T.SHELCAL -XT PO/OD X 15DAYS
TAB.NODOSIS 500MG PO/OD X 1MONTH
INJ HAI S/C TID 8U-10U-8U
Follow Up
REVIEW TO GM OPD AFTER 15DAYS/SOS

Comments

Post a Comment

Popular posts from this blog

60 year old male with loss of consciousness

Image
 A 60 years old male patient came to casuality with loss of consciousness at 2 Am  HOPI :  Patient was apparently alright and asymptomatic 12 days and then he experienced slip and fall on 15/4/24 and was taken to government hospital there he was diagnosed as intertrochanteric hip fracture and then shifted to ot there they have undergone surgery . On 17/4/24 patient developed altered sensorium and is so irritable and for further four days he is under observation of doctors and the concerned doctors did not inform the accurate cause to the patient attenders and then he was discharged  After discharge patient was at home with same irritable condition and altered sensorium for four days and again on 24/4/24 he suddenly developed SOB and then the patient attenders  admitted him to hospital there he had undergone CT brain suggested age related changes and for SOB they followed conservative treatment and altered sensorium is present And on Saturday at 2 Am patient loss consciousness so they s
Read more

65F Heart failure with preserved ejection fraction , ITP

Image
 A 65 years old female came to opd with c/o breathlessness since one week, insidious onset gradually progressive, grade 2-3 nyha, aggrevated on exertion, relieved with rest HOPI:  Patient was apparently asymptomatic 10 days back then developed shortness of breath. H/o generalized weakness and easy fatiguability  No h/o chest pain, palpitations, syncope, orthopnea, pnd No h/o cough, cold, fever, abdominal distension, facial puffiness, pedal edema, decreased urine output Past history:  h/o similar complaints in 2010, got 3prbc transfusions for Anemia, normal bone marrow biopsy, negative direct indirect coombs, in 2011 treated with steroids K/C/O: 2mnths back got dental procedure done, associated with blood loss, and started on steroids N/K/C/O : DM/ HTN /CAD / CVA / ASTHMA / THYROID /SEIZURE DISORDERS Personal history :  _ occupation : homemaker Patient is married  Patient takes mixed diet appetite is lost  Bowel and bladder movements are regular Micturition is normal  No known allergies
Read more

DIABETIC KETOACIDOSIS [RESOLVED] WITH DENOVO DIABETES MELLITUS SECONDARY TO ACUTE ON CHRONIC PANCREATITIS

 Case History and Clinical Findings C/O PAIN ABDOMEN SINCE 3 DAYS. PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED PAIN ABDOMEN SINCE 3 DAYS INSIDIOUS IN ONSET, LEFT LUMBAR REGION, SPASTIC TYPE OF PAIN,NON RADIATING. A/W VOMITING 3 EPISODES PER DAY A/W LOSS OF APPETITE SINCE 3 DAYS H/O CONSTIPATION SINCE 3 DAYS,STEATORRHOEA H/O BLOATING NO H/O FEVER ,LOOSE STOOLS NO H/O BURNING MICTURITION NO H/O DECREASED URINE OUTPUT PAST HISTORY: H/O SIMILAR COMPLAINTS IN THE PAST N/K/C/O HTN,DM,CVA,CAD,EPILEPSY,ASTHMA NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA. VITALS: BP:130/80 TEMP:97 RR:31 COURSE IN HOSPITAL: THIS IS A CASE OF 36 YR OLD MALE CAME WITH C/O PAIN ABDOMEN SINCE 3 DAYS A/W VOMITINGS 3-4 EPISODES PER DAY.PATIENT WAS EVALUATED AND DIAGNIOSED WITH DIABETIC KETOACIDOSIS,ACUTE O CHRONIC PANCREATITIS PATIENT WAS ADVISED FOR CECT ABDOMEN I/V/O PANCREATITIS BUT PATIENT AND ATTENDR DENIED FOR IT. ANTIBIOTICS ADEQATE,REHYDRATION WITH FLUIDS,SUGAR CONTROL
Read more