58 YEAR OLD FEMALE WITH UNCONTROLED SUGARS

 NAME : M. NAGA VARSHA 

BATCH : 2017

ADMISSION NO. 176015


This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

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.

FOLLOWING IS THE VIEW OF MY CASE

CHIEF COMPLAINTS:

c/o blurring of right eye since 1 year

c/o increased thirst since 1 year

HISTORY OF PRESENT ILLNESS

patient was apparently asymptomatic then she developed blurring of eyes       back, then she came to ophthalmology opd for right eye checkup(cataract) but on routine examination found to have high sugars rbs : 354mg/dl.

  • 10 years ago she noticed her wounds were not healing(on left toe) and on checkup was found to have high sugars and was diagnosed as type 2 DM. 
  •   she was started on OHA's an9d was continued for 2years.
  • later she was shifted to insulin injections (mixtard) due to uncontrolled sugars and continued for 2 years again.
  • and again shifted to insulin OHA's i/v/o - continued for 2 years 
  • and shifted to insulin inj(mixtard) for 2 years
  • now she is in on inj insulin mixtard.
c/o decreased sensation on both feet since 2 years
c/o of burning micturition
c/o of polyphagia, polydipsia 
no c/o tingling sensation, burning sensation on and off in both the lower limbs
no c/o nocturia
known case of hypertension since 3 years ( on medication of tab. METOPROLOL 50mg po/od)


PAST HISTORY 

not a known case of CAD,CVD, thyroid disorders epilepsy
No history of surgeries

DIET HISTORY :

8-8:30 AM - idly/ raagi jaava
                           tea ( with pinch of sugar)
12 PM - rice 
                 curry 
4 PM - Tea ( with pinch of sugar )
8 PM - 2 chapati 
               curry

PERSONAL HISTORY :

  1. Diet: mixed
  2. Appetite: increased
  3. Bowel habits: normal
  4. Bladder habits: normal
  5. Sleep: normal
  6. Addictions: 
                                    (i) alcohol consumption - occasional toddy consumption
FAMILY HISTORY :

histoty of diabetes - father, mother , sister 

MENSTRUAL HISTORY :

age of menarche : 13 years 
no. of living children : one ( 3 children died at the age of 14 years)


                                   
GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.
Examined after taking valid informed consent in a well enlightened room.
  • Pallor          - absent
  • Icterus        - absent
  • Clubbing    -absent
  • Lymphadenopathy    - absent
  • Cyanosis     - absent
  • Pedal edema  -absent










VITALS :
  • Temperature afebrile
  • Pulse : 82 bpm 
  • Respiratory rate : 16 per minute 
  • Bp 130/80
  • Spo2 98%
  • GRBS 244 mg%
CVS EXAMINATION 

 S1 S2 heard
no murmurs

RESPIRATORY SYSTEM
Bilateral air entrty present
NVBS

PER ABDOMEN 

soft, non tender

CNS EXAMINATION :

INVESTIGATIONS :

















PROVISIONAL DIAGNOSIS:

uncontrolled sugars
k/c/o diabetes since 10 years

TREATMENT GIVEN 

1. strict diabetic diet
2. INJ HAI 8 units - 6 hourly
3. INJ. NPH 4 units - 6 hourly
4. tab. metoprolol 50 mg po od




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