65 year old female with uncontrolled diabetes

Hi , I am Yeddula Vishnu Priya, 5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's 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 elog also reflects my patient centered online learning portfolio

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

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 which was high grade intermittent, associated with chills and rigors

2 injections and dolo associated with body pains and weakness no aggravating and relieved by medication

Patient was taken to near by hospital and was found to have high blood sugar levels and was treated conservatively.

Patient also complaint about SOB since 3 days which is grade 2-3, which increased on lying down and relieved by sitting.

No c/o chest pain, palpitations

Normal urine output and no burning micturition

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

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

At the same time she was diagnosed with Hypertension and was on medication since then

She also had an history of thorn pick to the right foot and developed ulcer over the base of the right foot.

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.

Mixed diet

Decreased appetite

Adequate sleep

Regular Bowel and bladder movements

Teetotaler

FAMILY HISTORY:

Not significant.

SURGICAL HISTORY:

ABDOMINAL HISTERECTOMY 25 YEARS AGO

General examination::

Patient is conscious,coherent , cooperative well