A 65 year old female with fever ,sob and uncontrolled sugars
A 65 year old female daily labourer by occupation,resident of suryapet came to the opd with chief complaints of
Fever and SOB since 3 days.
HOPI :
Pateint was apparently asymptomatic 3 days back then she developed fever which is high grade intermittent, associated with chills and rigors associated with body pains and weakness.
Patient was taken to near by hospital and was found to have high sugars and treated conservatively.
Patient also complaint about SOB since 3 days which is grade 2-3, increased on lying down and relieved by sitting.
No c/o chest pain, palpitations,PND.
Normal urine output
No c/o pedal edema, facial puffiness
c/o tingling sensation of hands and feet
C/o ulcer over Right foot after thorn pick injury
Five years ago patient developed giddiness for which she went to local hospital in suryapet and was diagnosis as Diabetic type 2.Since then she was on medication
1 year ago she went for hospital for sudden left hemiperesis which was diagnosed as CVA.They were given ECOSPRIN as medication.
At the same time she was diagnosed with Hypertension and was on medication since then.
TELMA 40 MG
She also had an history of thorn pick to the right foot and developed ulcer over the base of the right foot.
PAST HISTORY:
Patient is a known case of DM 2 since 4 yrs.
On medication insulin from 1 year
H.Mixtard 25Units BBF 40 Units BD
K/C/O HTN 1 year on medication
K/C/O CVA Since 1 year with hemiperesis
And on medication ECOSPRIN .
Not a known case of CAD, Thyroid disorders, Asthma and epilepsy.
PERSONAL HISTORY:
Daily routine: Daily labourer by occupation
She wakes up at 6 in the morning and freshens up. Have tea at 8 AM and goes to the field work by 9 in the morning. She takes lunch at 1:30 PM. Around 5 PM he comes back to his house.
She has dinner by 8 PM and goes to bed at 9:30 PM.
DIET: MIXED.
APPETITE: DECREASED
SLEEP: ADEQUATE.
BOWEL AND BLADDER: REGULAR ADDICTIONS: NO ADDICTIONS
FAMILY HISTORY:
Not significant.
SURGICAL HISTORY:
ABDOMINAL HISTERECTOMY 25 YEARS AGO
General examination::
Patient is conscious,coherent , cooperative well known with time, place, person
He is well built and moderately nourish
Pallor present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: absent
VITALS:
TEMP:97.2F
PR:80bpm
RR:17cpm
BP:130/80
Spo2: 97% @ RA
GRBS: 547mg/dl
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appear normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type.
Trachea central in position & Nipples are in 5th Intercoastal space
No dilated veins,sinuses, visible pulsations
Palpation :
Apex beat can be palpable in 5th inter
Costal space
Auscultation :
S1,S2 are heard
no murmurs
PER ABDOMEN
Shape of abdomen-scaphoid
Tenderness-No
Palpable mass-No
Liver- Not palpableS
pleen - Not palpable
Bowel sounds- Normal
CNS:
Tone. UL. LL
Rt. Normal normal
Lf. Normal. Normal
Power of right and left UL and LL is
5/5 and 4/5
Reflexes. B T. S. K. A. plantar
Lt: 2+. 2+. +. 3+. -.M
Rt: 2+. 2+. +. 3+. -. M
Provisional Daignosis::
UNCONTROLLED SUGARS WITH K/C/O DM2 4 YEARS AND HTN 1YEAR.
CVA LEFT HEMIPERESIS SINCE 1 YEAR.
INVESTIGATIONS::
USG ::
Chest x ray::
