50years old homemaker with generalized weakness, dryness of mouth and dizziness (occasional) since 4 years.

50years old homemaker with generalized weakness, dryness of mouth and dizziness (occasional) since 4 years.

August 6 , 2023 

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through

 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box 

 " I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan "

Unit posting (Intern 2017)

Medical Ward 

GM II 

Dr Nikitha

Dr Haripriya

Dr Govardhini

Dr rahul

CHIEF COMPLAINTS

50 years old female, housewife by occupation presented with the chief complaints of generalized weakness, dryness of mouth and dizziness (occasional) since 4 years.

HISTORY OF PRESENTING ILLNESS

● Patient was apparently asymptomatic 4 years ago, then she developed neck pain on and off which was dragging type and was unable to lift her hands (less than 15 degree)

Visited physician and was diagnosed with CERVICAL SPONDYLOSIS 

Treated with pain relieving medications and PhysiotherapyPhysiotherapy and was relieved.

● At the same time she was diagnosed with DM 2 and on medication.

First 3 years she was on some unknown medication.

Last 1 year she's on T. Vildagliptin +T.Metformin 50/500 mg PO/OD.

But sometimes she stops taking medicines on her own because she feels like she is fine.Again after few days she takes medicines.

No C/O   nocturia,polyphagia,polydypsia,polyuria.

No tingling sensation

She feels numbness in both the hands after waking up in the morning.

● Patient gave a h/o generalized weakness and dizziness on prolong standing. 

So after standing standing for sometime,she takes a sit or lie down.

● C/o dryness of mouth(occaional) since 4 years.

She said that she drinks 4-5 ltrs of water a day

No dry eyes

No Dry skin, no itching

● Patient also has complaints of - Diminision of vision,foreign body sensation since 3 years.

Lacrimation on and off since 3 years.

● C/O Pain in the PIP joints (in both hands) and unable to make fist since 2 years.

There is no morning stiffness.

No other small joint pain.

● C/o B/L knee pain, on and off since 2-3 months

Aggravates on walking and relieves on taking rest.

● C/o lower back pain, on and off , agrravates on prolonged sitting and relieves on taking rest.

● C/o sleep disturbances occasionally (monthly once or twice)

Some days she can't sleep for the entire night.

PAST HISTORY

K/c/o DM 2 since 4 years

and on regular medication.(T. Vildagliptin +T.Metformin 50/500 mg PO/OD)

Not a k/c/o Asthma,Thyroid disorder,epilepsy,TB, CAD,CVA

PAST SURGICAL HISTORY

H/O C-section 20 years ago

H/o laparoscopic Cholecystectomy 8 years ago.

MENSTRUAL HISTORY

Attained menopause 5 years ago.

Previous history-

•age of menarchy 14 years.

•Regular 30 days cycle

•She bleeds for 2-3 days

MARITAL HISTORY

She got married at the age of 26,

Conceived spontaneously

Gave birth to a girl child through C-section.

No abortion,no miscarriage

PERSONAL HISTORY

she takes mixed diet,

Bowel and bladder movements are regular

Sleep is disturbed

Appetite is normal

Addictions- betel leaf, betel nut,chewable tobacco since 10-12 years

DAILY ROUTINE

She has small nuclear family with her husband and college going daughter.

She starts her day around 6 am,

After that she goes for a morning walk in fresh air for about half an hour.

She does her house chores after coming back.

Then she takes her daily medication for diabetes(sometimes skips)and after 15 minutes  she drinks tea,biscuits.

Then again she involves herself in house chores as she doesn't have any maid to help her out.

She cooks for 3 members (her,her husband and her daughter)

Sometimes around 11 am she takes rice with boiled vegetables and boiled egg with her daughter (before she leaves for college)

Someday she skips this breakfast and directly takes lunch.

Usually she takes her lunch around 2 pm(takes rice,dal,vegetables,fish)

Then on she watches TV, roams around her home,stitches,weaves wool and waits for her daughter to come back from college.

After her daughter comes back, she spends time with her, perform puja as daily ritual.

Then they take their snacks.

Again she prepares dinner for all three of them and around 11pm they take their dinner(rice or chapathi)and go to bed.

GENERAL EXAMINATION 

Well informed consent is taken. Examined in a well lit room.

Patient is conscious coherent and coperative well oriented to time place and person.

Moderately built and moderately Nourished. 

Black spot in both the feet.

On left foot since 6-7 months,insidious in onset, gradually progressee to present size.

In the right foot since 4-5 months.

Not a/w with pain or itching 

Vitals 

Afebrile

BP 130/70mmhg

PR 76bpm

Respiratory rate 18 cpm

Mild pallor present

There is no icterus, clubbing, cyanosis or lympathadenopathy,Pedal Edema 

SYSTEMIC  EXAMINATION 

Abdominal examination 

Soft, non tender.

Bowel sounds heard.

Cardiovascular system examination 

S1 and S2 heard , no added thrills and murmurs heard.

Respiratory system examination 

BAE +

Normal vesicular breath sounds heard 

No adventitious sounds

 

CNS EXAMINATION:

No abnormality detected.

■ CRANIAL NERVES:

Intact

■ MOTOR SYSTEM:

No visible muscle wasting is seen on inspection.

■TONE OF THE MUSCLE:

Right: upper limb—Normal tone

           lower limb—Normal tone

Left:Upper limb—-Normal tone

        lower limb—-Norma tone.

■ POWER OF MUSCLE:

Right upper limb: 5/5

Right lower limb:5/5

■ POSTURE AND GAIT: 

No abnormal seen.

No involuntary movements or tremors are seen

■ Reflexes Right Left

   Biceps. ++ ++

   Triceps ++ ++

  Supinator. ++. ++

   Knee. ++. ++

   Ankle. ++. ++

   Plantar. Mute. Mute

INVESTIGATION

PROVISIONAL DIAGNOSIS

DM 2 since 4 years with k/c/o Cervical spondylosis 4 years ago

TREATMENT

Tab. Vildagliptin +Tab.Metformin 50/500 mg PO/OD

Ophthalmology opinion on 8/8/23

And is advised to take -

1.E/D OLAPAT 3TIMES A DAY

2.E/D LUBRREX 6 TIMES A DAY

3.E/D MOXIFLOX 6 TIMES A DAY