GM-elog

 This is online E log book to discuss our patients health data shared after taking his guardians informed consent form.


I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings
 investigations and come with a diagnosis and treatment plan. 


Case in brief

Date of Admission:27/07/22

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 antiglycemic 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(bedi)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 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


DIAGNOSIS 

Uncontrolled Diabetes mellitus 

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

28/7/22 

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

29/7/22
  
Tab.BENFOTHIAMINE PO/BD
Tab.GLIMI-M1 PO/BD
 Tab PREGABA-M 75mg
 
 Vitals
  29/07/22
 BP 110/70mm Hg 
PR 68/min

30/7/22
GRBS monitoring
12pm-321-HAl 4units sc


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

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