58YEAR OLD MALE PATIENT
September 22,2022
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58 year old male patient came to the GM OPD with cheif complaints of
-tingling and burning sensation in both soles since 1 year
-decreased eyesigh(right eye) since 2 months
HISTORY OF PRESENT ILLNESS
He is farmer.he used to wake up at 6 am in the morning and returns home by 5 pm and sleeps at 9 pm
patient was apparently asymptomatic 10 years back.Then he developped pain and burning sensation during micturition and decreased urine output,for which he went to a local hospital and he was told that he have kidney disease and medication wa given.Hi symptoms were resolved initially but later symptoms were on and off. He was diagnosed with Type 2 DM 3 years back.He is on medication(glimiperide and metformin)since 3 years.patient also developped backpain since 3 years.Patient also developped burning and tingling sensation in both soles since 1 year.His eyesight(right eye)decreased since 2 months.
PAST HISTORY
-B/L knee pain since 20 years
-K/C/O kidney disease since 10 years
-K/C/O Type2 DM since 3 years(on medication(GLUCORYL-M1-glimiperide and metformin)
-N/K/C/O-Asthma,Epilepsy,BP,Thyroid,CVA,CAD
PERSONAL HISTORY
Appetite-normal
Diet-mixed
Bowel and bladder movements-regular
Sleep-adequate
Alcohol-stopped since 20 years
Smoking-no
FAMILY HISTORY
His brother is diabetic since 5 years
GENERAL EXAMINATION
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema-absent
VITALS
BP-100/80mmHg
PR-84bpm
RR-20cpm
TEMP-98.5°F
SPO2-99% at RA
GRBS-150mg/dl
SYSTEMIC EXAMINATION
=>CVS
S1S2+
No thrills
No murmurs
=>R/S
BAE+
NVBS-heard
Dyspnoea-absent
Wheeze-absent
No adventitious sounds heard
=>P/A
Soft,nontender
Shape of the abdomen-scaphoid
No palpable mass present
Hernial orifices-normal
No free fluid
Liver-not palpable
Spleen-not palpable
Bowel sounds-heard
=>CNS
patient is conscious coherent and cooperative
Speech-normal
No signs of meningeal irritation
NFND
PROVISIONAL DIAGNOSIS
TYPE2 DM WITH PERIPHERAL NEUROPATHY
INVESTIGATIONS
22/09/2022
TREATMENT
1)TAB.GLIPIZIDE 3MG PO/OD
2)TAB.GABENTIN 100MG PO/HS
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