GOPAL BANOTH ROLL NO 4965/F WITH UNCONTROLLED SUGARS

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 

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

ABDOMINAL HISTERECTOMY 25 YEARS AGO

General examination::

Patient is conscious,coherent , cooperative well known with time, place, person 

He is well built and moderately nourish

Pallor present 
Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent 

VITALS:

TEMP:97.2F

PR:80bpm

RR:17cpm

BP:130/80

Spo2: 97% @ RA

GRBS: 547mg/dl



SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.










Comments

Post a Comment

Popular posts from this blog

39 YEAR OLD WITH SHORTNESS OF BREATH

Image
Y.Navya sahithi reddy Roll no.1701006200 2017 batch 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 A 37 year old male came to opd with c/o shortness of breath grade 4 since 3 months . HISTORY OF PRESENTING ILLNESS:-  Patient was apparently asymptomatic 2 years back ,  then the patient had an episode of giddiness ?due to shock (from the death of his brother in law) ,for which he went to a local hospital and got diagnosed with hypertension. Since then the patient was started on increasing doses of Telma and later Telma -H, but the patient was not compliant to the medication. He used to take the medication only when there's occasional neck stiffness and pain. History of mild shortness of breath and chest pain 3 months back, not associated with cough, fatigue
Read more

General medicine online assignment(covid case 23)

  Y.Navya sahithi reddy rollno 146 8th semster COVID-19 CASE -23 Covid 19 with multiple comorbidities: 1 )What do you think are the factors in this patient that are contributing to his increased severity of symptoms and infection?  Ans: As the patient has previous past history of : Type 2 Diabetes Mellitus since 7 years  Chronic Kidney Disease since 2 years Pulmonary Kochs: 7 years back for which he took 6 months of ATT. Bronchial Asthma since 7 years  Chronic NSAID use: since 1991 for knee pain  Getting admitted to a Hospital in 2019 for B/L Pneumonia. These above factors are contributing to his severity of symptoms and infection. 2.Can you explain why the D dimer levels are increasing in this patient?  Ans:The liver produces several important proteins involved in the coagulation process, one of which includes fibrinogen. A single fibrinogen molecule is a symmetrical dimer that is made up of three pairs of three different polypeptide chains, which include a, b and g. Each of the inter
Read more

INTERNAL ASSESMENT

Image
⁰ 10 Marks questions: 1 )Define bone density, how is it measured? What are the causes, clinical features,diagnosis and management of osteoporosis? (1+2+2+2+3) Bone density, or bone mineral density, is the amount of bone mineral in bone tissue.  Bone density measurements are used to diagnose osteoporosis . A bone density test is used to measure bone mineral content and density. It may be done using X-rays, dual-energy X-ray absorptiometry (DEXA or DXA), or a special CT scan  It is painless and tests the risk of fracture due to osteoporosis.  Osteoporosis is characterized by decrease in the amount of bone. Causes: primary- postmenopausal women and older men                      Secondary- cancer,COPD,CKD,certain drugs,                                                    Endocrine diseases.  Clinical features: usually asymptomatic                                Back ache or spontaneous fractures may be seen. Investigations: x rays showing osteopenia                
Read more