60 yr/Male with Dyspepsia and Typ:2 DM

 60 yr old male resident of  Nalgonda farmer by occupation came with

C/o: Tightness and pain in abdomen:1 month

C/o : Easy fatiguability 15 days

C/o dizziness : 4 days. 

HOPI:

Patient was apparently asymptomatic 1 month back then he developed tightness and pain in abdomen which was insidious onset dragging type, non radiating no aggravating and relieving factors . He also complaints of  cough with sputum(white in colour) not blood stained. 

C/o of polyuria (8 times/ day) 

No C/o burning Micturition, decrease output. 

K/c/o Type:2 DM on medication

Glimi M1


Patient was N/k/c/o HTN,  asthma, CAD. 



Past History:

No H/o similar complaints in the past. 


No past surgical History




PERSONAL HISTORY :-


Marital status : married 


Diet : mixed 


Appetite : normal


Bowel and bladder: regular


Sleep : adequate




Addictions : 


Alcohol :consumes 90 ml whiskey daily: 10 yrs


Beedi smoking occasionally. 




GENERAL EXAMINATION:-




Patient was concious coherent cooperative well built and nourished , well oriented to time place and person at the time of presentation.


Vitals:


Temp: 97.2 F


B. P:110/70 MMHG


PR:90


RR:18


Spo2:99@RA


GRBS:241 mg/dL



Pallor : present


Icterus : absent


Cyanosis : absent 


Lymphadenopathy : absent 


Edema : absent


SYSTEMIC EXAMINATION:-


I) Per Abdomen :


INSPECTION :-


Shape of abdomen -Flat


Umbilicus - inverted


No scars, sinuses, straie


No visible pulsations & visible peristalsis


Movements of all 4 quadrants moving equally with respiration




Palpation:



All inspectory findings are confirmed


No local rise of temperature


Tenderness present in the epigastric region


No palpable mass present


No palpable lymphadenopathy


No organomegaly


Hernial orificies - Free




PERCUSSION :-


No signs of fluid thrill & shifting dullness


Resonant note heard (except liver dullness)




AUSCULTATION :-


Bowel sounds present


No bruit heard




CNS:-


HIGHER MENTAL FUNCTIONS:


Oriented to time place and person 


Immediate memory:Intact


Short term memory:Intact


Longterm memory:Intact


No delusions and hallucinations.




Motor system


Power:-




Rt UL - 5/5 Lt UL-5/5


Rt LL - 5/5 Lt LL-5/5




Tone:-




Rt UL - normal


Lt LL- normal


Rt LL- normal


Lt LL- normal


Reflexes: 

                   Right                       Left

Biceps:         ++                           ++


Triceps:       ++                          ++


Supinator:  ++                         ++


Knee:           ++                       ++


Ankle:           + +                     ++


Plantar:          flexor.         Flexor


CVS:-


S1S2 heard,no murmurs.


Respiratory system examination


Bilateral air entry present.


Normal vesicular breath sounds present.











Diagnosis:

Dyspepsia with type 2 DM


Treatment:

Syp. Lactose 15ml/PO/BD

T. Glimi M1 PO/OD

T. Ultracet 1/2 tab. QID

T. Pan 40 mg Po/OD


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