60/F with Diabetes

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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 a diagnosis and treatment plan.

Name:- Kattekola Sathwik

Roll No :- 75

Case Report :-

60/F farmer came with complaints of

Tingling sensation of both lower limbs since 3 years

complaints of bilateral knee pain since 5 years

Complaints of burning micturition since 3 years

patient was apparently asymptomatic 10 years ago then  she developed tingling sensations,numbness and burning sensations of both lower limbs since 10 years(slrt-negative)

Complaints of bilateral knee pains since 5 years which is insidious in onset gradually progressive , crepitus present no morning stiffness, tenderness,swelling

aggravating with prolonged standing and on activity and relieving on rest and generalised body pains 

Complaints of burning micturition since 3 years which is not associated with fever with chills,frequency,urgency,hesitancy,

poor stream of urine,dribbling of urine

(Aggravates after eating non veg)

No h/o trauma

No h/o polyuria,polydypsia,polyphagia

No h/o chest pain,sob,palpitations

No c/o fever,pain abdomen,vomiting,loose stools,cough,cold

Past History

H/o renal calculi 7 years ago

H/o ?cerebral malaria 10 years ago

K/c/o DM since 20 years(on medication of tab.metformin 500mg po/bd)

 Not a k/c/o Tb,epilepsy,bronchial asthma,cva,cad,HTN

Personal History 

She takes mixed diet 

sleep normal

stools  regular 

micturation- burning micturition since 3 yrs

no addictions

no significant family history

On examination 

no pallor icterus cyanosis clubbing pedal edema lymphadenopathy 

BP:-130/70 mmhg

PR 80 bpm

GRBS:-346mg/dl

CVS: s1s2 heard

RS :-  b/l air entry present ,NVBS

PA: soft,non tender, no organomegaly

cns:hmf intact

Sensory Examination 

Clinical Images 

Investigation 

USG abdomen and pelvis 

2D echo 

ECG 

Chest X ray PA

Hemogram

CUE

FBS 

PLBS :- 304mg/dL

X Ray lumbar spine AP

X ray Lumbar Spine Lateral 

Interpretation :- 

Degenerative changes In Lumbar spine 

Osteophytes seen

Loss of Lumbar Lordosis

In view of Right hydronephrosis Urology referral was done on 25.03.2023

In view of ? Lumbar spondylosis and B/L Knee osteoarthritis Orthopedics referral was done 

Inview of ? Diabetic Retinopathy an Ophthalmology Referral was done on 25.03.2023

Final diagnosis

UNCONTROLLED TYPE 2 DIABETES WITH LBA SECONDARY TO RADICULOPATHY WITH OSTEOARTHRITIS OF BILATERAL KNEES AND LUMBAR SPINE WITH HISTORY OF RENAL CALCULI WITH RIGHT HUN 

Treatment Given 

1. Tab.MVT PO OD 

2. Tab.Glimi M1 Po OD 

3.Tab PREGABALIN  PO OD

4.Tab.ULTRACET PO BD