a63yr old female came to gm opd with c/o sob and chest pain and palpitations.

A 63 yr old female  came to  GM opd with the cheif complaints of shortness of breath , palpitations and burning pain in the stomach. Since 1 year. 

HOPI:

Pt was apparently asymptomatic 1yr back
and she had an injury to her right leg and didn't got treatment for that. Later on that infection got severed and her total body has swollen  and experienced shortness of breath and pricking pain in the chest and after that she went to a local hospital and got tested and treated. 
In the tests she was told to have heart problem and kidney problem. 
Then she also took medications for that problem. 
But that shortness breath and chest pain is not relieved. 
Patient also told about decreased urine output. 
Patient also complaining about tingling sensation in the soles b/l.
No h/o Polyuria, polyphagia, polydypsia. 
No h/o fever. 
No h/o vomiting. 
No h/o diarrhoea. 

PAST HISTORY
Not a k/c/o  DM, HTN, ASTHMA, EPILEPSY, TB

PERSONAL HISTORY:
Appetite is decreased. 
Mixed type of diet. 
Sleep adequate. 
Decreased bowel and bladder movements. 

TREATMENT HISTORY:
She took medications in the past for her renal. problem .( Unknown) 
Got treatment for her injured foot. 

GENERAL EXAMINATION
pt is malnourished cooperative coordinated and coherent. 
No pallor, icterus ,cyanosis ,clubbing, Koilonochia, lymphadenopathy, pedal edema. 

SYSTEMIC EXAMINATION

CVS
S1 S2 heard 
Murmurs heard 

Respiratory system
Trachea central
Normal vesicular breath sounds heard

Cns
No focal neurological deficits . 

Per abdomen:
Scaphoid abdomen
No organomegaly
No tenderness and localised raise of temperature. 

INVESTIGATIONS

RANDOM  BLOOD SUGAR LEVELS

       COMPLETE URINE EXAMINATION

                    HEMOGRAM

                              RFT
                                 LFT
 Serological Tests

Provisional diagnosis:

Uncontrollable sugar levels DENOVO DM II
peptic acid disease

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