40 yr female with burning sensation of palms
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I have 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.
Case
A 40 yr old female pt with
chief complaints of burning sensation in palms since 2 months insidious in onset , gradually progressive increased intensity at night is seen
Not associated with tingling sensation , numbness,paresthesias .
No c/o polyphagia,polydypsia,polyuria,nocturia
K/c/o diabetes mellitus since 3 yrs
On medication glimi M1 po od
Past history
She has no similar complaints in past.
Is not a known case of htn,tb,asthma,seizures, thyroid disorders.
Pt got diagnosed as diabetic when visited a hospital for regular checkup 3 yrs ago
She is uneducated and working as a laundry iron woman since childhood (from 15 yrs) she got married in teenage (at 15 yrs) .Has her first child ( at 16yrs) and second child at 18 yrs . Both the babies delivered through LSCS due to baby wt (4 kg) .
Diet : mixed
Appetite : normal
Bowel and bladder : regular
Sleep : inadequate due to complaints
Addiction: none
General examination
Patient is conscious , coherent, co operative
No
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Oedema
Pallor : present
Temp:98.5°F
Bp: 140/80 mmhg
PR:84 bpm
RR: 18cpm
Systemic examination
Cvs :
Precordium normal
No thrills ,
On auscultation
S1,S2 heard ,no murmurs
CNS:
Higher mental functions :intact
Cranial nerves :intact
Motor system:Normal power,tone,Gait
Reflexes:normal
Sensory examination:Normal
No meningeal signs
Tremors : absent
Rs:
Shape of chest:Bilaterally symmetrical, Elliptical in shape
No visible chest deformities
No kyphoscoliosis,
Abdomino thoracic respiration, No irregular respiration
Trachea is central
Auscultation:
Normal vesicular breath sounds heard
P/A
INSPECTION:
Shape of abdomen:Distended
Umbilicus:inverted
Skin over the abdomen is normal with striae.
All quadrants are moving equally with respiration
No visible peristalsis, Hernial orifices intact
External genitalia normal
PALPATION:
Temperature:Not raised
Tenderness:Absent
No Rebound tenderness
No guarding rigidity
No organomegaly
Percussion
No shifting dullness ,
No fluid thrill
Auscultation
Bowel sounds are heard.
Investigations
On 3/7/23
FBS : 246 MG/DL
PLBS: 410 MG/ DL
HbA1C: 7.4%
Serum creatinine :0.6 mg/DL
ECG:
On 4/7/23
Blood urea : 24 mg/dl
Serum creatinine : 0.7 mg/dl
Stool for occult blood : negative
Reticulocyte count : 1%
Serum ferritin : 3.1 ng/ml
Normal 11- 306.8
Serum iron : 42 ug/dl
Chest x ray PA view
On 4/7
5 pm: 254
7pm.: 248
10 pm :312 inj . hai 4 nph 6
On 5/7
2am: 243
8 am: 245 inj hai nph 6 units each
10 am : 98
1pm 305 10units hai
On 4/7
5 pm 254
7pm. 248
10 pm 312 hai 4 nph 6
On 5/7
2am 243
8 am 245 hai nph 6 units each
10 am 98
1pm :305 10units hai inj
4 pm :331
7 pm ;211 inj 6 units each hai,nph
10 pm : 201
On 6/7
2 am :172
8 am :253
4 pm: 331
7 pm: 211 6 units each hai,nph inj
10 pm: 201
On 6/7
2 am :172
8 am: 253
Diagnosis
Uncontrolled sugars
K/c/o DM 2 since 3 yrs
Iron deficiency anemia secondary to nutritional /blood loss
Treatment
Inj HAI s/c tid acc to grbs
8 am ,2 pm,8 pm
Inj nph sc/bd
Inj iron sucrose 200 mg in 100 ml ns /iv /bd
Tab orofer xt po/od
Tab limcee po/od
Patient got discharged on 7/7
Advised
Inj hai 10 units sc/tid
Inj nph sc /bd 8 units
8 am,8 pm
Tab .orofer. Xt po/od for 1 month
Tab . Limcee po/od for 1 week
