45 YEAR OLD FEMALE WITH TYPE 2 DIABETES MELLITUS




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-centred 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.


CHIEF COMPLAINTS:

C/O Neck pain since 6 years
       Low back pain since 3 years
       Pain in right upper abdomen since 3 years.

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 6 years back then she had polyuria for which she undergone routine investigation and was diagnosed with diabetes mellitus   
• Neck pain on and off since 6 years, radiating to shoulders associated with headache, which is diffuse type. 
•Low back pain  since 3 years on and off ,non radiating type aggrevated when sitting for long time.
•  Pain in right upper abdomen since 3 years, on and off ,last episode is 3 days back

• K/C/ O Hypertension since  2 years but not on regular medication.

PAST HISTORY:

No History of ASTHAMA, TB , EPILEPSY, CAD,CVA.

FAMILY HISTORY:

No similar complaints in the family.

Personal history:
Diet- mixed
Appetite- normal 
Bowel and bladder movements- Regular
Tobacco- chewable since 3 months.

GENERAL EXAMINATION:

Pt is conscious, coherent and cooperative 

No pallor, no icterus, no Cyanosis, no clubbing, no lymphadenopathy



VITALS- day 1


TEMP-98.6 F

BP-110/80 MM HG

PR- 86 bpm

RR-16/min

GRBS- 258 mg/dl

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling.

PALPATION:  Soft, tenderness inTENDERNESS IN RIGHT ILIAC FOSSA, LEFT ILIAC FOSSA, HYPOGASTRIUM.
 No organo megaly.

  AUSCULTATION:BOWEL SOUNDS HEARD

CARDIOVASCULAR SYSTEM:

    No visible pulsations, scars, engorged veins. No rise in jvp 

   Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

    S1 S2 heard . No murmurs.

- RESPIRATORY SYSTEM:

    Shape of chest is elliptical, b/l symmetrical.

    Trachea is central. Expansion of chest is symmetrical

      Bilateral Airway Entry - positive

      Normal vesicular breath sounds

CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.

INVESTIGATIONS:


TREATMENT:

Tab. GLIMIPERIDE 2mg + METFORMIN 1000 mg PO/BD.

 VITALS DAY 2

TEMP- Afebrile

BP-130/80 MM HG

PR- 82 bpm

RR-16/min

P/A - SOFT, TENDERNESS IN RIGHT ILIAC FOSSA, LEFT ILIAC FOSSA, HYPOGASTRIUM.

CVS- S1,S2 HEARD, NO MURMURS

RS- BLAE+, NO ADDED SOUNDS.

TREATMENT:

1.Tab. GLIMIPERIDE 2mg + METFORMIN 1000 mg PO/BD.
2. GRBS 7 POINT PROFILE MONITORING.
Day 3:


Tab metformin 1000 mg BD ( after food ) 

Tab Glimiperide 2.5 mg BD ( before food ) 

And Continue 7 point profile.
















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