A 60 year old woman with Uncontrolled Type2 DM

 


E LOG GENERAL MEDICINE 

Hi, I am shaik karishma , 3rd Sem Medical Student.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 inputs on the 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. 

A 60 year old woman from nalgonda, who is a housewife came to OPD with the chief complaint of-

Decreased appetite since 3 days

Vomiting(whatever she consumed) since 2 days

Fever since 6 days

Shortness of breath since 3 days


History of present illness-

She has been complaining with decreased appetite, vomiting and fever since 6 months which increased during nights and lasts for 6-8 days and relieved on medication.


She has been previously admitted here 6-8 months ago with a complaint of fever and discharged after attaining normal temperature on medication.


Past illness-

She was also diagnosed with renal failure 3 years ago


She has been diagnosed 20 years ago with type-2 DM for which she takes insulin injection and with Hypertension.


Personal History-

Diet: mixed

Appetite: decreased 

Sleep: hypersomnia

Bowel: irregular(once in 8-10days since 6 months)

Bladder: frequent urination(polyuria) and incontinence 

Addictions: pan 


Family History-

No significant family history 


General Examination:

Patient was conscious coherent and cooperative

Pallor - present 

No Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy


Vitals-

Pulse: 72bpm

GRBS : 128mg/dl @4.30pm


Provisional Diagnosis-

Uncontrolled Type2 Diabetes Mellitus 




Chief Complaints:

Comments

Post a Comment

Popular posts from this blog

67/M WITH SOB AND FEVER

Image
11/06/23 Hi, I am shaik karishma , 5th Sem Medical Student.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 inputs on the comment box is welcome.” I have 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. CHIEF COMPLAINTS :  A 67 year old male barber by occupation, came to the opd with chief complaints of Shortness of breath s...
Read more

44 yr male with CKD,CAD and hypertension

Image
23/08/2022  Eblog4 Hi, I am shaik karishma , 3rd Sem Medical Student.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 inputs on the 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.  CHIEF COMPLAINTS: A 44 yr old male came was admitted in the hospital on 28/07/2022 with complaints of shortne...
Read more

13 year old boy with massive spleenomegaly

Image
 September 01, 2022 Hi, I am shaik karishma , 3rd Sem Medical Student.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 inputs on the 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.  CHEIF COMPLAINTS The patient came with swelling in the left side of abdomen since 15 days and was suffering wi...
Read more