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

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