General medicine

SRINAINI 

Roll no:- 33

5th semester 


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.

D.O.A:- 27/07/22

#This is an ongoing case and will be updated .

Case in brief
A 50yr old male ,farmer by occupation came to opd ,for deaddiction.


Chief complaints
• Generalized weakness since 15days
• Polydipsia
• Polyuria

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.

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 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 be 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

Random Blood sugar


Complete blood picture

Glycated haemoglobin


Blood urea

Complete urine examination


Serum potassium


Serum creatinine


Serum electrolytes

Liver function test

USG abdomen -impression

Fatty infilteration of liver 

Mild hepatomegaly

Coarse texture of liver 



DIAGNOSIS

Uncontrolled Diabetes

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

28/7/22

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

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