50years old homemaker with generalized weakness.
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Unit posting (Intern 2017)
Medical Ward
GM II
Dr Nikitha
Dr Haripriya
Dr Govardhini
Dr Stimita
CHIEF COMPLAINTS
50 years old female, housewife by occupation presented with the chief complaints of generalized weakness, dryness of mouth and dizziness (occasional) since 4 years.
HISTORY OF PRESENTING ILLNESS
● Patient was apparently asymptomatic 4 years ago, then she developed neck pain on and off which was dragging type and was unable to lift her hands (less than 15 degree)
Visited physician and was diagnosed with CERVICAL SPONDYLOSIS
Treated with pain relieving medications and PhysiotherapyPhysiotherapy and was relieved.
● At the same time she was diagnosed with DM 2 and on medication.
First 3 years she was on some unknown medication.
Last 1 year she's on T. Vildagliptin +T.Metformin 50/500 mg PO/OD.
But sometimes she stops taking medicines on her own because she feels like she is fine.Again after few days she takes medicines.
No C/O nocturia,polyphagia,polydypsia,polyuria.
No tingling sensation
She feels numbness in both the hands after waking up in the morning.
● Patient gave a h/o generalized weakness and dizziness on prolong standing.
So after standing standing for sometime,she takes a sit or lie down.
● C/o dryness of mouth(occaional) since 4 years.
She said that she drinks 4-5 ltrs of water a day
No dry eyes
No Dry skin, no itching
● Patient also has complaints of - Diminision of vision,foreign body sensation since 3 years.
Lacrimation on and off since 3 years.
● C/O Pain in the PIP joints (in both hands) and unable to make fist since 2 years.
There is no morning stiffness.
No other small joint pain.
● C/o B/L knee pain, on and off since 2-3 months
Aggravates on walking and relieves on taking rest.
● C/o lower back pain, on and off , agrravates on prolonged sitting and relieves on taking rest.
● C/o sleep disturbances occasionally (monthly once or twice)
Some days she can't sleep for the entire night.
PAST HISTORY
K/c/o DM 2 since 4 years
and on regular medication.(T. Vildagliptin +T.Metformin 50/500 mg PO/OD)
Not a k/c/o Asthma,Thyroid disorder,epilepsy,TB, CAD,CVA
PAST SURGICAL HISTORY
H/O C-section 20 years ago
H/o laparoscopic Cholecystectomy 8 years ago.
MENSTRUAL HISTORY
Attained menopause 5 years ago.
Previous history-
•age of menarchy 14 years.
•Regular 30 days cycle
•She bleeds for 2-3 days
MARITAL HISTORY
She got married at the age of 26,
Conceived spontaneously
Gave birth to a girl child through C-section.
No abortion,no miscarriage
PERSONAL HISTORY
she takes mixed diet,
Bowel and bladder movements are regular
Sleep is disturbed
Appetite is normal
Addictions- betel leaf, betel nut,chewable tobacco since 10-12 years
DAILY ROUTINE
She has small nuclear family with her husband and college going daughter.
She starts her day around 6 am,
After that she goes for a morning walk in fresh air for about half an hour.
She does her house chores after coming back.
Then she takes her daily medication for diabetes(sometimes skips)and after 15 minutes she drinks tea,biscuits.
Then again she involves herself in house chores as she doesn't have any maid to help her out.
She cooks for 3 members (her,her husband and her daughter)
Sometimes around 11 am she takes rice with boiled vegetables and boiled egg with her daughter (before she leaves for college)
Someday she skips this breakfast and directly takes lunch.
Usually she takes her lunch around 2 pm(takes rice,dal,vegetables,fish)
Then on she watches TV, roams around her home,stitches,weaves wool and waits for her daughter to come back from college.
After her daughter comes back, she spends time with her, perform puja as daily ritual.
Then they take their snacks.
Again she prepares dinner for all three of them and around 11pm they take their dinner(rice or chapathi)and go to bed.
GENERAL EXAMINATION
Well informed consent is taken. Examined in a well lit room.
Patient is conscious coherent and coperative well oriented to time place and person.
Moderately built and moderately Nourished.
Black spot in both the feet.
On left foot since 6-7 months,insidious in onset, gradually progressee to present size.
In the right foot since 4-5 months.
Not a/w with pain or itching
Vitals
Afebrile
BP 130/70mmhg
PR 76bpm
Respiratory rate 18 cpm
Mild pallor present
There is no icterus, clubbing, cyanosis or lympathadenopathy,Pedal Edema
SYSTEMIC EXAMINATION
Abdominal examination
Soft, non tender.
Bowel sounds heard.
Cardiovascular system examination
S1 and S2 heard , no added thrills and murmurs heard.
Respiratory system examination
BAE +
Normal vesicular breath sounds heard
No adventitious sounds
CNS EXAMINATION:
No abnormality detected.
■ CRANIAL NERVES:
Intact
■ MOTOR SYSTEM:
No visible muscle wasting is seen on inspection.
■TONE OF THE MUSCLE:
Right: upper limb—Normal tone
lower limb—Normal tone
Left:Upper limb—-Normal tone
lower limb—-Norma tone.
■ POWER OF MUSCLE:
Right upper limb: 5/5
Right lower limb:5/5
■ POSTURE AND GAIT:
No abnormal seen.
No involuntary movements or tremors are seen
■ Reflexes Right Left
Biceps. ++ ++
Triceps ++ ++
Supinator. ++. ++
Knee. ++. ++
Ankle. ++. ++
Plantar. Mute. Mute
INVESTIGATION
PROVISIONAL DIAGNOSIS
DM 2 since 4 years with k/c/o Cervical spondylosis 4 years ago
TREATMENT
Tab. Vildagliptin +Tab.Metformin 50/500 mg PO/OD
Ophthalmology opinion on 8/8/23
1.E/D OLAPAT 3TIMES A DAY
2.E/D LUBRREX 6 TIMES A DAY
3.E/D MOXIFLOX 6 TIMES A DAY
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