GOPAL BANOTH ROLL NO 4965/F WITH UNCONTROLLED SUGARS
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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.
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