60F Tingling and Numbness
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A 60 year old female patient agricultural worker by occupation,resident of kodad came to general medicine department with C/o Tingling and numbness of both lower limbs from ankle to calf muscles since 1 year
HOPI
patient was apparently asymptomatic 10 months back,then she had tingling sensation and numbness of lower limbs from ankle to calf muscles which was insidious in onset,gradually progressive and lost sensation of foot.
She was taken to khammam private hospital with similar complaints,taken medication but not relieved
C/o Shortness of breath while walking few steps and stops for some time to take breath with no aggravating and relieving factors
Nocturia present
Polyphagia present
Polyuria absent
No c/o chest pain, palpitations, orthpnea and paroxysmal noturnal dysuria
No c/o burning micturition
No c/o fever,cough and cold
Past history
K/c/o diabetes since 30 years
K/c/o bronchial asthma since 30 years
K/c/o hypertension since 1 month
K/c/o CKD since 1 month
N/K/c/o epilepsy,TB
TREATMENT HISTORY
Drug history
Tab.Metformin 500mg three times a day for diabetes since 30 years
Levosalbutamol for bronchial asthma since 30 years and budesonide since 1 month
Tab.losartan for hypertension since 1 month
Past surgical history
Tubectomised 30 years back
Hysterectomy 20 years back
PERSONAL HISTORY
Patient takes mixed diet
Appetite decreased
Regular bowel and bladder movements
Sleep disturbed due to tingling and burning sensation of feet
Addictions - toddy drinker
FAMILY HISTORY
no significant family history
ALLERGIC HISTORY
no allergies to any kind of drugs or food items
GENERAL EXAMINATION
Patient is conscious, coherent, and cooperative
Moderately built and nourished
Pallor present
No icterus
No cyanosis
No clubbing
No lymphadenopathy
VITALS:
Temperature - Afebrile
Pulse Rate - 88 bpm
Respiratory Rate - 16cpm
Blood Pressure - 110/70mmHg
Sp02 - 99% at Room air
GRBS - 344 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
S1 ,S2 heard,no murmurs,no thrills
RESPIRATORY SYSTEM
INSPECTION
Bilateral Air entry Present
Trachea- central
Movements of Chest decreased on left side
Type of respiration- thoracoabdominal
On percussion, all lung fields are resonant
On auscultation Normal vesicular Breath sounds are heard, and there are no added sounds
Per abdomen examination
Soft and non-tender
No organomegaly
No palpable masses
CNS examination
Normal
No focal neurological deficit
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
DIABETES NEPHROPATHY WITH KNOWN CASE OF DIABETES,BRONCHIAL ASTHMA , HYPERTENSION AND CKD
TREATMENT
Nebulisation Duolin 6th hourly
Budesonide 12th hourly
Tab Losartan 50 mg po/oD
Tab metformin 500mg PO/BD
GRBS PROFILE
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