50 yr old male with uncontrolled type-2 diabetes mellitus

This is 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 patients clinical problems with collective current best evidence based inputs.This e-log also reflects patients centered learning portfolio.

Case in brief
A 50yr old male ,farmer by occupation came to opd ,for deaddiction 
Chief complaints
• Generalized weakness since 15days 
• Polydipsia
• Polyuria 
• itching 

History of present illness
• Patient was apparently asymptomatic 1yr back then he was diagnosed to have diabetes at a government camp.
• So then he was given oral antigycemic drugs ,he used it for 2months and stopped it.
• So, he developed generalized weakness, polydipsia, polyuria.
• Then he visited a private hospital at nakrekal,then was found to have high sugar levels ,since then he was started with insulin,but he was on a irregular medication. 
• He is even complaining of severe itching on legs and trunk.

History of past illness
• He was a k/c/o of type 2 diabetes 1year back.
• He was not a k/c/o hypertension, asthma,CAD, epilepsy

Treatment history
• He was on diabetic medication
• No history of use of any other medication 

Family history
• There is no significant family history 

Personal history
• Mixed diet 
• Normal appetite
• Normal bowel movements
• No known allergies
• Adequate sleep
• Habits-
• chronic alcoholic -180ml/day since 30yrs
     Tobacco smoking(beedi) since 30yrs 1pack/day
• Daily routine- He generally wakes up at 6:00am in the morning and at 7:00am he'll have his breakfast(rice) .And the goes for farming ,and then he'll have his lunch at 2:00pm and returns from farming at 6:00 in the evening and drinks alcohol and goes to bed around 9:00pm. 

GENERAL EXAMINATION 

on Examination,
patient is conscious,coherent,co - operative and well Oriented to time,place and person. 

There are no signs of. Icterus,cyanosis,clubbing,Lymphadenopathy and oedema 

There is presence of mild pallor.  

              

VITALS
Temperature: 98°F
PR: 82bpm
BP:90/60
RR:18/min
RBS-541mg/dl 

Sytemic examination 

C VS:
No thrills 

S1 and S2 + 

NO murmurs 

Respiratory system 

NO Dyspnoea 

NOWheeze 

Trachea is centrally located 

Abdomen 

soft and non tender 

NO palpable Mass 

Liver and Spleen are not palpable 

CNS

NAD 

  Investigations:











Ultra sound
Fatty infilteration of liver 

Mild hepatomegaly

Coarse texture of liver 


DIAGNOSIS 

Uncontrolled Diabetes 

TREATMENT
27/7/22
• Tab.BENFOTIAMINE PO/OD
• TAB.GLIMI -M1 PO/OD
• INJ. HAI 6units S.C
• GRBS monitoring 

28/7/22 

• Tab.BENFOTIAMINE PO/OD
• TAB.GLIMI -M1 PO/OD
• INJ. HAI 6units S.C
• GRBS monitoring

29/7/22
.Tab. BENFOTIAMINE PO/BD 
 Tab. GLIMI -M1 PO/BD 
Tab PREGABA- M 75mg 

Vitals 
29/07/22
BP 110/70mmHg
PR 68/min 
3pm - 325
  7pm - 466 - Tab.Glimi 2.5mg 
                      Tab metformin 1g/dl

   12am- Hi - HAI units SC
   4am - 177

  31/07/22
  8am - 239 
  1am - 348
   2pm- 324
   4pm-528 Glimi 4mg metformin 1g/dl
   10pm-345
    2am- Hi Glimi 4mg metformin 1g/dl

  01/08/22
  Glimi 4mg metformin 1g/dl
 8am-288 
 10am-352 
 1pm-200 
 4pm-394
 8pm-338 - Glimi 4mg metformin 1g/dl
 11pm-333
 2am-336
 
02/8/22 
Glimi 4mg metformin 1g/dl
 8am-155
 11:30am -318
 5:00pm-394
 8:00pm- 338
 10:30pm-477
 2:00am-362

 03/08/22
 8:00am-135
 12pm - 300
  8pm - 532
  10pm - 411
  2am - 320
  
04/08/22
 8am - 176

06/08/22
 10:30 am-272
                             

Comments

Post a Comment

Popular posts from this blog

Image
40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS    December 06, 2023   40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS  ** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required. Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified  health data shared, AFTER taking his/her/guardian's signed informed consent. Here, in this series of blogs, we discuss our various patients' 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. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to de
Read more

A 55 yr old male with lower back pain

Image
​ E-LOG GENERAL MEDICINE Hi, This is Kundana , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them Chief complaints:    Patient complains of shortness of breath , fever and lower back ache . shortness of breath since 10 days Lower back pain simce 10 days  History of present illness:   The patient is apparently asymptomatic one month ago , then he developed shortness of breath  shortness of breath: insidious onset , grade-2 (NYHA) , gradually progressive  History of orthopnea, PND, cough present No history of chest pain , cold  Decreased urine output since one month Thin stream , poor flow, increased frequency, hesitency sensations present, burning micturition present, but no pain during micturition Pain: at lower back , dull boring typ
Read more