63F PTB DM

 A 63 YR OLD FEMALE FARMER BY OCCUPATION FROM PEDHADEVULLAPALLI PRESENTED WITH CHIEF COMPLAINTS OF 

C/O B/L KNEE PAINS SINCE 4 YRS

C/O COUGH WITH SPUTUM SINCE 3 MONTHS

C/O FEVER SINCE 15 DAYS

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 YRS AGO WHEN SHE DEVELOPED B/L KNEE PAINS, NON RADIATING, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, AGGRAVATED ON WALKING, RELIEVED ON REST.

C/O COUGH WITH EXPECTORATION, SINCE 3 MONTHS, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, WHITE IN COLOUR, NO AGGRAVATING AND RELIEVING FACTORS,

 C/O FEVER SINCE 15 DAYS, HIGH GRADE, ASSOCIATED WITH CHILLS AND RIGORS, INTERMITTENT, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, NO DIURNAL VARIATION 

NO C/O NAUSEA, VOMITINGS, PAIN ABDOMEN 

NO C/O SOB, PALPITATIONS, ORTHOPNEA, PND 

NO C/O POLYURIA, POLYDIPSIA, POLYPHAGIA, NOCTURIA

NO C/O CHEST PAIN, CHEST TIGHTNESS H/O WEIGHT LOSS SINCE  3MONTHS

PATIENT WENT TO LOCAL HOSPITAL IN MIRYALAGUDA ONE MONTH AGO AND WAS TREATED WITH INJ PIPTAZ TID FOR 5 DAYS 

PAST HISTORY

K/C/O DM TYPE II SINCE 5 YRS ON T. SUGAGLIM M2{PATIENT HAD GENERALISED WEAKNESSS 5 YEARS AGO FOR WHICH SHE WENT TO LOCAL PRIVATE HOSPITAL AND WAS DIAGNOSED WITH DIABETES AND HER BLOOD SUGARS ARE 300MG/DL ACC TO ATTENDERS}

NK/C/O HTN, TB, THYROID, CVA, CAD, ASTHMA 

PERSONAL HISTORY 

DIET MIXED

OCCUPATION FARMER - STOPPED WORKING SINCE 4 YEARS DUE TO BILATERAL KNEE PAINS

BOWEL AND BLADDER REGULAR

LOSS OF APPETITE SINCE 3 MONTHS

LOSS OF WEIGHT SINCE 3 MONTHS

ALCOHOLIC TAKES 90ML/DAY  WHISKEY OR BRANDY SINCE 40 YEARS ONCE IN 2 DAYS

NON SMOKER

DAILY ROUTINE : LIVED WITH HUSBAND TILL HIS DEATH LATER STAYED ALONE FROM LAST 3 MONTHS SHE MOVED TO HER SON’S HOUSE AS SHE IS UNABLE TO DO HER ROUTINE ACTIVITIES.

WAKES UP AT 5 AM - FRESH UP AND CLEANS HOUSE BY 6 AM

TAKES TEA AT 6 AM AND COOKS BREAKFAST AND LUNCH AND WASHES CLOTHES BY 8.30 AM AFTER EATING BREAKFAST GOES TO WORK ALONG WITH HERHUSBAND FROM 9 TO 5 PM TAKES 2 HOURS BREAK FOR LUNCH AND AFTERNOON NAP.

RETURNS HOME BY 5 OR 6 PM COOKS DINNER WILL CONSUME ALCOHOL ALONG WITH HER HUSBAND TAKES DINNER AT 8 PM SLEEPS BY 9 PM.

HUSBAND EXPIRED11 YEARS AGO DUE TO ?INFECTION(HAD FEVER FOR ONE DAY AND DIED THE SAME NIGHT IN A PRIVATE HOSPITAL)

ON EXAMINATION

PATIENT IS CONSCIOUS, COHERENT AND CO-OPERATIVE TEMP 98.4 F

BP 100/60 MMHG

PR 90 BPM RR 18 CPM

CVS S1 S2+ NO MURMURS

CNS NFND

RS BAE+, CREPTS IN RT INTRASCAPULAR, INTERSCAPULAR AND INFRA AXILLARY AREA 

PER ABDOMEN :SOFT AND NON TENDER

Investigation

COMPLETE URINE EXAMINATION (CUE) 20-04-2024 04:11:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN +

SUGAR Nil

ESR:140

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 4-5

EPITHELIAL CELLS 3-4

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS NiT

AMORPHOUS DEPOSITS Absent

OTHERS NII

HBsAg-RAPID 20-04-2024 04:11:PM Negative

Anti HCV Antibodies - RAPID 20-04-2024 04:11:PM Non Reactive

RFT 20-04-2024 04:15:PM

UREA 35 mg/dl 50-17 mg/dl

CREATININE 0.9 mg/dl 1.2-0.6 mg/di

URIC ACID 2.2 mmol/L 6-2.6 mmol/L

CALCIUM 9.4 mg/dl 10.2-8.6 mg/di

PHOSPHOROUS 2.6 mg/d| 4.5-2.5 mg/dI

SODIUM 140 mmol/L 145-136 mmol/L

POTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.

CHLORIDE 101 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 20-04-2024 04:15:PM

Total Bilurubin 0.50 mg/dl 1-0 mg/di

Direct Bilurubin 0.17 mg/dl 0.2-0.0 mg/di

SGOT(AST) 15 IU/L 31-0 IU/L

SGPT(ALT) 10 IU/L 34-0 IU/L

ALKALINE PHOSPHATASE 148 IU/L 141-53 IU/L

TOTAL PROTEINS 6.8 gm/di 8.3-6.4 gm/dI

ALBUMIN 3.0 gm/di 4.6-3.2 gm/dl

A/G RATIO 0.82

HEMOGRAM : 20/4/24

HAEMOGLOBIN :7.8GM/DL

TOTAL COUNT:8000CELLS/CUMM

PLATELET COUNT - 3.74 LAKHS /CUMM

HEMOGRAM: ON 23/4/24

HAEMOGLOBIN :7.6GM/DL

TOTAL COUNT :8400CELLS/CUMM

NEUTROPHILS:75% LYMPHOCYTES : 18 %

EOSINOPHIL :00

MONOCYTES :07

BASOPHILS :00

PCV :23>7

МСН :24.8

MCV:76.6

MCHC:32.3

RDW :16.8

RDW SD:47.6

RBC COUNT :3.09 MILL/CUM

PLATELET COUNT 3.74 LAK/CUMM

SMEAR MICROCYTIC HYPOCHROMIC

PERIPHERAL SMEAR -

WBC: WITH NORMAL LIMITB PLATELET :ADEQUTE IN NUMBER

HEMOPARASITE NO HEMOPARASITES SEEN

IMPRESION MICROCYTE HYPOCHROMIC ANEMIA

ECG : IRREGULAR RHYTHM VPC'S IN LEAD2 AND 3.

HR- 80 BPM

SERUM IRON - 50.5 MICROGRAM /DL

SERUM FERRITIN - 355.2 NG/DL

RETICULOCYTE COUNT - 1.2 %

HRCT OF CHEST DONE ON 21/04/24

IMPRESSION - CONSOLIDATION WITH FEW THIN WALLED CAVITIES IN RIGHT LUNG LOWER LOBE

CENTRILOBULAR NODULES WITH A TREE IN BUD APPEARANCE IN RIGHT LUNG MIDDLE

LOBE

F/S/O INFECTIVE ETIOLOGY

2D ECHO DONE ON 20/04/24

IMPRESSION: TRIVIAL AR + / TR +, NO MR NO RWMA. NO AS/MS, SCLEROTIC AV.

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION +

NO PAH/PE/LV CLOT.

BRONCHOSCOPY DONE ON 23/04/24

IMPRESSION - NORMAL STUDY

BAL TRUNAAT -MTB DETECTED

Treatment Given(Enter only Generic Name)

STRICT DIABETIC DIET

TAB AZITHROMYCIN 500MG PO/OD

TAB AMOXYCLAV 625 MG PO/BD

TAB PAN 40 MG PO/OD

TAB ULTRACET 1 TAB PO/BD

SYP GRILINCTUS PO/TID

15ML-15ML-15ML

TAB SHELCAL CT PO/OD

TAB ZOFER 4MG PO/TID

BAL TRUMAAT - POSITIVE

TAB METFORMIN 500 MG PO/OD

TAB GLIMI M2 FORTE PO/OD

TAB PULMOCLEAR PO/BD

TAB MONTEK- LC PO/HS

ATT 3TABS/DAY