65/F WITH UNCONTROLLED SUGARS

July 28,2023


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

This E blog 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 diagnosis and treatment plan.

AMC

MEDICAL WARD

DOA:24/07/23

A 65 year old female daily labourer by occupation,resident of suryapet came to the opd with chief complaints of

Fever and SOB since 3 days.


HOPI :

Pateint was apparently asymptomatic 3 days back then she developed fever high grade intermittent, associated with chills and rigors associated with body pains and weakness.

Patient was taken to near by hospital and was found to have high sugars and treated conservatively.

Patient also complaint about SOB since 3 days which is grade 2-3, increased on lying down and relieved by sitting.

No c/o chest pain, palpitations,PND.

Normal urine output

No c/o pedal edema, facial puffiness

c/o tingling sensation of hands and feet

C/o ulcer over Right foot after thorn pick injury

Five years ago patient developed giddiness for which she went to local hospital in suryapet and was diagnosis as Diabetic type 2.Since then she was on medication 











1 year ago she went for hospital for sudden left hemiperesis which was diagnosed as CVA.They were given ECOSPRIN as medication.



At the same time she was diagnosed with Hypertension and was on medication since then.    


   

TELMA 40 MG

She also had an history of thorn pick to the right foot and developed ulcer over the base of the right foot.





PAST HISTORY:

Patient is a known case of DM 2  since 4 yrs.

On medication insulin from 1 year

H.Mixtard 25Units BBF 40 Units BD

K/C/O HTN 1 year on medication

K/C/O CVA Since 1 year with hemiperesis

And on medication ECOSPRIN .

Not a known case of CAD, Thyroid disorders, Asthma and epilepsy.


PERSONAL HISTORY:

Daily routine:  Daily labourer by occupation 

She wakes up at 6 in the morning and freshens up. Have tea at 8 AM and goes to the field work by 9 in the morning. She takes lunch at 1:30 PM. Around 5 PM he comes back to his house.

She has dinner by 8 PM and goes to bed at 9:30 PM.


DIET: MIXED.

APPETITE: DECREASED

SLEEP: ADEQUATE.

BOWEL AND BLADDER: REGULAR                  

ADDICTIONS: NO ADDICTIONS 


FAMILY HISTORY:

Not significant.


SURGICAL HISTORY:

Axillary- (NVBS) (NVBS)

Infra axillary-(NVBS) (CREPTS)                 

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- (NVBS)(NVBS)


CVS: 

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

Palpation :

Apex beat can be palpable in 5th inter co

stal space


Auscultation : 

S1,S2 are heard

no murmurs


PER ABDOMEN

**Shape of abdomen-scaphoid

**Tenderness-No

** Palpable mass-No

** Liver- Not palpable

**Spleen - Not palpable

**Bowel sounds- Normal

CNS:  


Tone. UL. LL

Rt. Normal normal

Lf. Normal. Normal


Power of right and left UL and LL is 

5/5 and 4/5

Reflexes. B T. S. K. A. plantar

          Lt: 2+. 2+. +. 3+. -.M

          Rt: 2+. 2+. +. 3+. -. M


Provisional Daignosis::

**UNCONTROLLED SUGARS WITH K/C/O DM2  4 YEARS AND HTN 1YEAR.

** CVA LEFT HEMIPERESIS SINCE 1 YEAR.

INVESTIGATIONS:















USG ::



Chest x ray




Treatment plan::

1.HAI 6 UNITS IV STAT

2.HAI INFUSION @6ML/HR

3.IV FLUIDS NS @100 ML/HR

4.INJ PAN 40MG IV/OD

5.TAB ECOSPRIN  AV 75/10 PO/HS

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