GENERAL MEDICINE E-LOG

  • This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians 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. 

Date of admission: 13/06/22 

CHIEF COMPLAINT: 

A patient aged 52 years old female came to the opd for a follow up with chief complaints of 

  • Generalised weakness 
  • Dizziness 
HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 8 years back , then she was diagnosed with diabetes mellitus type II. 

1 month back patient developed tinea corporis on lateral side of left side of the leg for which she took medication and noticed that it wasnt healing properly even after taking the medication. Then she consulted a doctor and  noticed that her blood sugar levels were increasing. 

She was on medication( insulin injections) for her uncontrolled blood sugar levels for 15 days

1 day back she was having generalized weakness and noticed that her blood sugar levels were increasing even after taking the medication. 

Patient also had complaints of bilateral shoulder pain and difficulty in lifting the shoulder for 2-3 months for which she is on medication 

HISTORY OF PAST ILLNESS: 

Patient is a k/c/o of DM II and on medication( Inj. NPH and HAI)

Patient is also a k/c/o HTN and on medication( T.TELMA 40mg) 

Not a k/c/o asthma,CAD,TB 

TREATMENT HISTORY: 

Patient had undergone a surgery for hernia

Patient also had undergone a surgery for b/l parotid gland enlargement. 

PERSONAL HISTORY:

  • Appetite is normal 
  • Having mixed diet 
  • Bowels regular 
  • Micturition normal 
  • No habit of drinking 
  • No habit of smoking 
  • No other habits/ addictions 

GENERAL EXMINATION:

Patient is conscious, coherent

Absence of pallor, icterus, clubbing, cyanosis, pedal edema, lymphadenopathy.

VITALS: 

1.Temperature: afebrile 

2.Pulse rate: 100 beats per min

3.Respiratory rate: 22 cycles per min 

4.BP: 120/80mm Hg

5.SpO2: 98% @ Room air 

6.GRBS: 190mg%  

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

  • S1, S2 heard
  • No thrills, No murmurs

RESPIRATORY SYSTEM:

  • Normal vesicular breath sounds
  • Position of trachea is central
  • Dyspnea is absent 
  • No wheeze

EXAMINATION OF ABDOMEN:

  • Shape- scaphoid
  • No tenderness
  • No palpable pass
  • Normal hernial orifices 
  • No free fluid
  • No Bruits
  • Liver is not palpable
  • spleen is not palpable
  • Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

  • Patient is conscious 
  • Speech is normal 
  • No focal neurological defect
  • All reflexes were present 
  • Absence of cerebral signs 

PROVISIONAL DIAGNOSIS: 

DM II( uncontrolled sugars) 

TINEA CORPORIS 

K/c/o HTN with SUPRASPINATOUS TEAR 

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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