A 65 year old female patient came to general medicine OPD with the chief complaints of blurred vision and burning sensation in feet

Hi, I am More Ishan  of 5th semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.



The patient’s consent was taken verbally prior to history taking and examination of his/her condition.

A 65 year old married female patient, housemaker by occupation came from Errapally to general medicine OPD with the chief complaints of burning sensation in both feet since 1 year and blurring vision since 10 days 


HISTORY OF PRESENT ILLNESS 

The patient was apparently asymptomatic 1 year ago. Then she gradually developed burning sensation in both the feet while walking which was progressive over days.
3 days ago she experienced episodes of blurring of vision just after meals which subsided in the next 1-2 hrs. She complains of 2 episodes per day one in the morning and other in evening time after having lunch and dinner respectively everyday until she was admitted in the hospital 3 days ago.
She had no associated headache, nausea, vomiting, fever, tinnitus, sweating, palpitations. 
She complains of decreased appetite since 3 days due to the fear of experiencing symptoms. 

HISTORY OF PAST ILLNESS 

She was diagnosed as diabetic and hypertensive 5 years ago in a hospital in Miryalaguda to where she went with the complains of body pains.
She was using regular medication until 10- 15 days ago from which she missed the dose every alternate day. 
No other significant past history.



FAMILY HISTORY 

No significant family history. 


PERSONAL HISTORY 

Married housemaker
Mixed diet
Decreased appetite
Regular bowel movement 
Normal bladder movement
Adequate sleep 
No allergies 
Consumes toddy 1 glass per month
No history of smoking


DRUG HISTORY 

since 5 years 
• Tab Amlodipine 5mg OD
• Tab Metformin 500mg OD - irregular intake(alternate days) 

After admission 
• Tab Telmisartan 40 mg OD
• Inj insulin 40 units OD


GENERAL EXAMINATION 

Physical examination 

Patient was conscious coherent and cooperative 
Moderately built and Moderately nourished 
No pallor 
No icterus 
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
No pedal edema 

Vitals 

Heart rate - 96 bpm
Blood pressure- 150/80 mmHg

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