52yr old with uncontrolled diabetes

E-LOGS GENERAL MEDICINE

 
Roll no 04 
Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 patients clinical problems with collective current best evidence based inputs. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

A 52yr old female patient came to the OPD with complaints of generalised weakness and dizziness .


HISTORY OF PRESENT ILLNESS: 
Patient was asymptomatic 1 month ago , when she developed a swelling over her leg which was then found out to be due to tinea corporis . Which did not heal on taking medicine , which suspected them of high blood sugars in association with symptoms of it i.e, dizziness , high urine output especially at night . 
She visited the casualty 15 days ago with dizziness , where she was admitted and was on insulin for 6 days . 
She then got discharged and was recommended to use insulin at home . 
Blood glucose levels were normal until then when she got tested . Patient started to feel dizzy again and she came to casualty .

PAST HISTORY: 
K/c/o HTN 
k/c/o DM
Surgical history: hernia 

PERSONAL HISTORY: 
Diet : mixed 
Appetite: normal 
Bowel and bladder movements: normal 
Addictions : normal
Sleep : normal ?

FAMILY HISTORY: 
No significant family history

GENERAL EXAMINATION: 
Pallor - not seen 
Cyanosis -not seen
Icterus -not seen 
Lymphadenopathy - not seen 
Clubbing - not seen 
Oedema - not seen 

VITALS :
Temperature: afebrile
Pulse rate: 100/min 
Respiratory rate : 22/min 
BP: 110/80 
SpO2 : 98%

SYSTEMIC EXAMINATION: 
CVS : 
S1 S2 heard 

RESPIRATORY SYSTEM: 
BAE +

ABDOMEN: 
scaphoid shaped 
Non tender 

CNS : 
NFND 

PROVISIONAL DIAGNOSIS: 
*UNCONTROLLED DIABETES
*TINEA CORPORIS

INVESTIGATIONS : 





TREATMENT: 
 * Inj NPH 
* GRBS monitoring 6th hrly 
* TAB ZINCOVIT PO /OD
* TAB TELMA 40mg PO/OD 
*TAB PREGABA po H/S 
*TAB ULTRACET 






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