65 year old female

DOA:24/07/23

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 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:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (CREPTS)

Axillary- (NVBS) (NVBS)

Infra axillary-(NVBS) (CREPTS)                 

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- (NVBS)(NVBS)

CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation :

Apex beat can be palpable in 5th inter co

stal space



Auscultation : 

S1,S2 are heard

no murmurs



PER ABDOMEN

**Shape of abdomen-scaphoid

**Tenderness-No

** Palpable mass-No

** Liver- Not palpable

**Spleen - 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

Treatment plan::

1.HAI 6 UNITS IV STAT

2.HAI INFUSION @6ML/HR

3.IV FLUIDS NS @100 ML/HR

4.INJ PAN 40MG IV/OD

5.TAB ECOSPRIN  AV 75/10 PO/HS


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