Sarojini DM Long Case 1902102055
A 65 year old female patient came with
Blurring of vison , Constipation and Burning Micturition.
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CHIEF COMPLAINT
A 65 year old female patient Agricultural Labourer by occupation came to opd with complaint of bluring of vision, buring of Micturition , Constipation
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic two years back
Patient experienced blurring of vision since 2 years
Patient experienced increased sweating since 2-3 months
Patient suffering constipation and passes stools once in 2-3 days
HISTORY OF PAST ILLNESS
No h/o Tb ,epilepsy,Asthma
Has h/o DB type 2 since 2 years and was on irregular medications
FAMILY HISTORY
No significant complaints in family history
TREATMENT HISTORY
SURGERIES : Tubectomited 25 years ago
PERSONAL HISTORY:-
Married
Appetite- Lost 1 year back
Diet - Vegetarian
Bowel and bladder- Constipation passes stools once in 2-3 days
Micturition - Polyuria since 2 years
No known allergies
Habits- No Habits
MENSTRUAL HISTORY
Attained Menopause 15 years ago
GENERAL EXAMINATION
Pallor-No
Pedal edema- No
No clubbing of fingers ,cyanosis,icterus,lymphadenopathy
VITALS
Temperature-Afebrile
Pulse rate -78bpm
Bp-110/90mm of Hg
spo2-98%
GRBS - 400 mg%
SYSTEMIC EXAMINATION:
CVS
S1 &S2 heard
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM
INSPECTION
Size and shape -bilaterally symmetrical
Position of trachea-central
Apical impulse-not seen
Chest expansion-symmetrical
PALPATION:
Trachea- midline
Chest movements- symmetrical
No intercoastal widening
PERCUSSION
No tenderness over chest wall
No added sounds
No pleural rub
Right Left
Supraclavicular R R
Infraavicular R R
Mammary R. R
Infra mammary R R
Axillary R R
Infra axillary R R
Suprascapular R R
Interscapular R R
Infrascapular R R
AUSCULTATION
Normal vesicular breath sounds heard
Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS NVBS
Axillary NVBS NVBS
Infra Axillary NVBS NVBS
Suprascapular NVBS NVBS
Interscapular NVBS NVBS
Infrascapular NVBS NVBS
ABDOMEN
INSPECTION
Shape of abdomen: Obese
Surface of abdomen has no scars , no dilated veins , No visible peristalsis
PALPATION
Liver and spleen not palpable
PERCUSSION
Resonance sound is not heard
AUSCULTATION
Bowel sounds are not heard
CNS
Patient is conscious
Speech normal
No neck stiffness
Motor and sensory system- Normal
PROVIOSIONAL DIAGNOSIS
Diabeties Mellitus Type 2
Diabetiec Neuropathy
INVESTIGATIONS ORDERED
FBS 150 mg %
PLBS 210 mg%
TREATMENT
Inj HAI 6 units I.V. Stat
Correctol 50 plus
