60/F PTB DM2 CAD

 A 60 years old female resident of Nalgonda ,maid by occupation presented to the OPD with chief complaints of 


Cough since 15 days
Fever since 15 days

HISTORY OF PRESENTING ILLNESS 
Patient was apparently asymptomatic 15 days back after which he developed cough insidious in onset mucoid in nature with blood in sputum 4to 5 episodes, less than 10 ml,no aggrevating factors and relieved on medication .
Fever since 15 days ,high grade associated with chills and rigor ,vomitings which was non bilious 2 episodes. Patient also had shortness of breath not associated with wheeze, orthopnea,paroxysmal dyspnoea. No seasonal and diurnal variation. 

History of loss of weight since 1 month,associated with generalised weakness and also complained of chest tightness

No history of sweating, palpitations, decrease in urine output 

HISTORY OF PAST ILLNESS 

No history of similar complaints in the past 
History of cardiac surgery(CABG) in the past 6 years ago and on medication (Tab Acitron,furosemide,ecospirin).
No history of TB in the past 
Known case of DM and is on oral hypoglycemics on metformin, glimipiride,voglibose since 8 years
Not a known case of HYPERTENSION, thyroid disorders and epilepsy 

TREATMENT HISTORY 
Known case of DM and is on oral hypoglycemics on metformin ,glimipiride,voglibose since 8 years

PAST HISTORY:

No history of similar complaints in the past

No history of of tuberculosis

She underwent cardiac surgery 6 yrs back(CABG),and is on furosemide,aspirin and oral acitrom(vit k epoxide reductase inhibitor)

Known case of Diabetics since 8 yrs,and on metformin,glimiperide,voglibose( alpha glucosidase inhibitor)

Not history of HTN,ASTHMA,THYROID ABNORMALITIES,EPILEPSY.

History of 4 blood transfusions during cardiacs surgery.

PERSONAL HISTORY:

Sleep adequate 

Appetite normal

Bowel and bladder regular

No allergies

Takes alcohol occasionally  60ml whiskey once a week 

Regular smoker ,smokes 5 chutta per day.

Family history:

Both parents are diabetic 

Father had a history of heart attack.

No  history of HTN ASTHMA COPD in the family

MENSTRUAL HISTORY :

 MENARCHE  attained at 13 yrs

Age of menopause 40 yrs

OBSTETRIC HISTORY:

Married since 40 yrs.

GENERAL PHYSICAL EXAMINATION:

Patient is conscious coherent and cooperative well oriented to time, place and person 

Moderately built and well nourished 

No pallor cyanosis icterus clubbing lympadenopathy edema

Temp:100.2 F

PR :94bpm

Bp: 100/70

Spo2 :99per

GRBS: 135 mg/ dl.

SYSTEMIC EXAMINATION:

CVS S1 S2 heard,no murmurs.

CNS :No focal neurological deficits 

ABDOMEN:Soft,non tender, no organomegaly 

RESPIRATORY EXAMINATION:

Upper respiratory examination:

no DNS ,no polys,no post nasal drip,no pharyngeal wall inflamation.

Oral cavity  shows dental caries present, 2 teeth are lost.

Inspection:

Shape of the  chest  is elliptical

chest movements are symmetrical on both sides

Trachea appears to be central ( trails sign negative)

No crowding of ribs drooping of shoulders 

No wasting of muscles

No use of accessory muscles of respiration 

Apical pulse is not seen

No kyphosis and scoliosis

No scars,sinuses seen.

Palpation:

All inspectors findings are confirmed by palpation

No local rise of Temperature 

Anterior posterior diameters is about 16cm

Transverse diameter 23cm

Chest circumference 63 cm 

Chest  circumference after inspiration is 68cm

Trachea is central - 3 finger test

 chest movements are symmetrical with respiration

Tactile vocal fremitus is equal on both sides 

Apical pulse is felt at 5th intercostal space 1 inch medial to MCL

No tenderness over the chest region.

Percussion:

Resonant in all areas of lungs

No tenderness on percussion 

Liver dullness at 5th ics

Cardiac dullness within  normal 

Auscultation:normal breath sounds heard 

INVESTIGATIONS:




X RAY 

2D ECHO

 
Sputum CBNAAT positive; antituberculosis therapy commenced on January 10, 2023. PATIENT WAS CONTACTED THROUGH CALLS ON APRIL 2023 AND PATIENT IS DOING FINE AND IS GOING FOR REGULAR CHECK UP AT LOCAL GOVERNAMENT HOSPITAL.

OUTCOME - COMPLETELY RECOVERED

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