37 year old female with pain in the right foot and tingling sensations
CHIEF COMPLAINT:
A 37 year old female patient who is a daily laborer by occupation came to OPD with the chief complaints of:
1)Right foot pain and tingling sensations since 4 days
2)Throat pain since 2 days
3)low back ache.
HOPI:
She was apparently asymptomatic 5 days back then she developed right foot pain which was dull in nature and aching type without any relieving factors. She developed throat pain which was insidious in onset, continuous in nature, gradually progressive, aggravated during change in weather, no relieving factors associated with pain during swallowing(odynophagia). There is change in her voice and nasal obstruction on both sides since 2 days. The nasal obstruction is insidious in onset, intermittent in nature, aggravated on exposure to cold.
Daily Routine:
She wakes up at 5:00, prepares and eat her breakfast mostly chapatti and then she used to go to work as she used to be a daily laborer by occupation. She used to carry bricks and sand near the construction sites. Since 3 days she stopped going to work due to pain in her right foot. She used to eat lunch on her work site and used to come to back to home by 7 pm. she used to have rice for lunch and dinner.
PAST HISTORY:
Patient had fever at the age of 16 years and after the evaluations, she was diagnosed with diabetes(MODY3) and started on oral hypoglycemic agents.
Patient had high fever with altered sensorium and admitted in hospital at the age of 18 years and was told about the increase in size of left kidney (?pyelonephritis). She stayed in hospital for 10 days for it.
At the age of 19 years, patient had (grade1) pedal edema and at the age of 21 years she had abdominal pain for which she takes antibiotics since then.
She is a k/c/o Type2 DM since 20 years and on medication of metformin
k/c/o left emphysematous pyelonephritis.
N/k/c/o HTN, TB, ASTHAMA, CAD, EPILEPSY.
FAMILY HISTORY:
Pedigree Chart:
PERSONAL HISTORY:
Married
Occupation: daily laborer
Diet: Vegetarian
Appetite: normal
Bowels: regular
Micturition: normal
Sleep: adequate
Habits: occasional alcohol drinker(beer on occasion)
Menstrual History:
age of menarche: 16 years
Obstetric history:
Age of marriage: 18 years
1st pregnancy of female -18 yrs of age
2nd pregnancy of male - 1.5 yr gap
3rd pregnancy of female - 1.5 yr gap
GENERAL EXAMINATION:
On examination patient is conscious, coherent and cooperative and well oriented to time, place and person and consent was taken to examine her.
Pallor: absent
Icterus: absent
Cyanosis: -
Clubbing: -
Lymphadenopathy: absent
Koilonychia: -
Pedal edema: absent
Dehydration: absent
VITALS:
BP:130/90 mm Hg
PR: 83bpm
RR: 17 cycles/min
SPO2: 98%
SYSTEMIC EXAMINATION:
CVS:
no thrills and murmurs heard
s1 and s2 sounds +
RS:
Dyspnea: absent
position of trachea is in central
vesicular breath sounds are heard
Abdomen:
non tender and no organomegaly detected
CNS:
conscious and normal in speech
cranial nerves are intact
sensory system is normal
motor system is normal
reflexes are normal
INVESTIGATIONS:
BLOOD SUGAR- FASTING:
POST LUNCH BLOOD SUGAR:
USG:
USG IMPRESSION: LEFT MILD HYDRONEPHROSIS, WITH ALTERED ECHOGENICITY AT UPPER POLE OF LEFT KIDNEY.
ECG:
Acute Pharyngitis
PLAN OF TREATMENT:
-Tab PCM 650mg BD- 1 week
-2% Betadine throat gargles diluted in glass of water- 2-3 times/day- 1 week.
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