54 F came with Diabetes for 3 years, weight loss of 8 to 10kgs in a year b/l tingling sensation in upper and lower limbs
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Dr. Sarbesh Mishra
Roll no.: 142
54 year old female came with c/o Diabetes for 3 years, weight loss of 8 to 10kgs in a year b/l tingling sensation in upper and lower limbs
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1 year back , then the patient had developed tingling and numbness in the B/L upper and lower limbs
Tingling started in the foot and palm and gradually progressed to B/L legs and hands.
No history of loss of sensation
No history of trauma / fall
History of polyuria +
No history of polyphagia and polydypsia
History of weight loss of 8 to 10 kgs in a year
No history of fever,cough, vomiting,
Burning micturition, shortness of breath , pedal edema and Giddiness
PAST HISTORY:-
No similar complaints in the past (before 1 years)
Known case of DM type 2 (+)since 3 years used medication for 2and half years Stopped the medication 6months back
Known case of HTN (+) since 8 years used medication for 6 years stopped the medication 2 years back
Not a know case of TB , bronchial asthma, epilepsy, CAD, thyroid.
SURGICAL HISTORY:-
She underwent a LSCS 33 years ago
FAMILY HISTORY:-
No family history of HTN, DM, bronchial asthma, epilepsy
PERSONAL HISTORY:-
Diet: Mixed
Appetite: Normal
Sleep: Normal
Bowel: regular
Bladder: normal
Habits : She has no addictions what so ever
No alcohol and no smoking habits
SOCIAL HISTORY AND DAILY ROUTINE:-
She is a house keeper by occupation
Married and has a child (boy)
Everyday she wakes up around 6am and starts preparing breakfast for her family
In breakfast she usually have puffed rice, Dall with rice and every one in her family have the same breakfast routine.
At around 11am she again eats the same food that is Dall with rice and sometimes added up with non veg food (chicken and mutton)
At 12pm she prepares lunch again for her family .....
Usually she prepares rice and mixed vegetables curry
And around 3pm she again has the lunch in a little bit quantity
Every day in the evening at around 6pm she has a drink which includes lemonade( non sweetened ) and Fenugreek seed (methi) or fennel seed (saunf) soaked in water the day earlier
Its her daily practice and someone told her that drinks that's she is having might cure her diabetes and she following it since 2 years
She goes for walk for around 3kms every single day in the Evening and returns back home and takes a bit rest for an hour while she goes to her kitchen for preparing the dinner
As usually she prepares rice and Dal mixed with vegetables or non veg according to their taste of interest
She doesn't take any food in the dinner neither chapati nor rice because she feels undigested
So she has the same puffed rice for the dinner that was made in the morning for her and her family , she complained about polyuria (6 to 7 times per day) and nocturia to her husband and her husband took her to a local hospital that's when she was diagnosed with diabetes
When her husband finds out that she gets angry and tensed on simple issues that happen at home and took her to the local hospital thats when she was diagnosed with hypertension and she said it ranges around 150/90 to 170/100, She said she stopped having medication for both the diabetes and hypertension because she feels like the medication she is taking doens't cure her diabetes or hypertension
But she takes medication for diabetes whenever she feels like the nocturia is increased ........
GENERAL EXAMINATION:
The patient was examined after taking consent in a well lit room
Patient is conscious,coherent , cooperative,
Oriented to time , place and person
She is moderately built and nourished
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Edema: Absent
Vitals:
PR: 84 BPM
RR: 16 cpm
BP: 120/70mmHg
SpO2: 98%
Temperature: 98.4°F
GRBS: 180 mg/dl
CLINICAL IMAGES:
SYSTEMIC EXAMINATION:
CVS:
On inspection:
Precordium is normal
Apex impulse could not be seen
No visible pulsations
On palpation:
Apex beat localised to 5th intercostal space medial to mid clavicular line.
No parasternal heave
No palpable thrills
On auscultation:
S1 and S2 heard.
No cardiac murmurs heard.
RS:
On inspection:
Chest shape is elliptical
Expands equally on inspiration
Trachea: central
On palpation:
Tactile vocal fremitus is equal in all areas
On percussion:
Resonant note on all regions.
On auscultation:
Bilateral air entry positive
Vesicular breath sounds are heard.
No adventitious sounds such as crepts, rochi, etc heard.
ABDOMEN:
On inspection
Abdomen is scaphoid.
Umbilicus is central and inverted
No scars or sinuses
On palpation:
Abdomen is soft
No tenderness
No organomegally.
On auscultation:
Bowel sounds heard.
CNS:
Cerebellar functions normal
Cranial nerve examination normal
Sensory examination: normal
Motor examination:
R. L
Tone:
UL. N. N
LL. N. N
Power:
UL. 5/5 5/5
LL. 5/5 5/5
Reflexes:
Biceps. ++. ++
Triceps. ++. ++
Knee. ++. ++
Ankle. +.+
INVESTIGATIONS:
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