General Medicine case discussion
36 year old male with Uncontrolled sugars.
This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed
I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency I reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Roll no 125
S.Neeraja Reddy
A 35 year old male resident of nalgonda lecturer by occupation presented to the opd on 15th/03/2022 with chief complaints of
Pain in the left lower chest region since 1 week
Vomitings since 3 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 7 years ago when he was diagnosed with diabetes mellitus after an episode of giddiness.Then he was started on OHAs.
He used go for checkups and took medication(Metformin)regularly and Sugars were under control with good dietary control.
Until 2008 he used be an occasional drinker but since 3 years due to some personal issues started drinking about 750 ml of alcohol per day.Since then he was on irregular medication and 2 weeks later he developed sudden abdominal pain and vomiting.
He was hospitalized and diagnosed with acute pancreatitis .He was given insulin for high blood sugar levels then shifted to GLYCOMET -MV1
Thereafter he stopped alcohol for about 2months.
He again developed recurrent similar episodes of abdominal pain and vomiting followed by heavy drinking again for which he used to stop taking alcohol for 2 days and resumed again.
3 years ago he complained of corn on the plantar aspect of great toe of left foot.patient used to cut the thickened part with blade.
1 year ago it turned into ulcer for which debridement was done .
He does his own dressing of the ulcer with spirit and iodine every alternate day but it was not healed and also associated with pain.Pain got radiated to ankle.
2 years ago he does suicide attempt and also quit his job but occasionally taught as guest lecturer.
19 days ago he had an accident when was drunk developed pain and swelling but neglected it because he was on alcohol binge for 3 days.
Pain is of throbbing type non radiating aggravated by taking deep breaths and lying in left lateral position and relieved by medication..
14 days ago he had an episode of vomiting at night which was blood stained.He stopped taking alcohol.
Next day there was about 10 to 15 episodes of vomiting ,non bilious initially later into bilious non projectile . Contents as food particles.
He also developed sudden increase in pain of lower chest region for which he came to the hospital.
Patient didnot take any medication since 10days.
He was given Zofer for vomitings and IV fluids were given and his sugar levels were 500-600mg/ dl he was put on Insulin for first 2 days he was normal then he developed itching all over the body for next 2 days then he had severe itching all over the body ( avil was given) so insulin was stopped and was given oral medication glimiperide 4mg morning , metformin 500 mg morning and glimiperide - 3 mg , metformin 500 mg night.
He wanted to go for de - addiction but his sugar levels are not controlled so he was sent back.
Past history
Diagnosed as Diabetic 8 years ago
▪No history of hypertension, asthma, epilepsy, Tuberculosis,CAD
Family history
Not significant
Personal history
Diet- mixed
Appetite- normal ( does not take food when he consumes alcohol )
Sleep- inadequate( when he does not take alcohol)
Bowel and bladder movements- regular
Habits- consumes alcohol from 2009 occasionally but from 2019 consumed daily(5 days per week,each time about 750 ml Perday)
5 to 6 cigarettes per day.
Clinical images
General examination
Patient was conscious , coherent, cooperative well oriented to time , place and person
Pallor- mild
icterus- absent
cyanosis- absent
clubbing- absent
Lymphadenopathy - absent
Edema- absent
Vitals
Afebrile
Pulse rate 72bpm
Bp130/90mmhg
Respiratory rate 18cpm
GRBS charting
• 15/3/2022- 500 to 600 mg/dl
•16/3/2022
2AM (16/3/22): 101mg/dl
6AM (16/3/22): 97 mg/d
8 AM ( 16/3/22): 144 mg/dl
*From 17th March to 19th March
Before breakfast and dinner -glimiperide 3 mg
After breakfast and dinner -metformin 500 mg
Breakfast -3 idli and ragi Java
Lunch-3 chapathi
Dinner-java+fruits
•18/03/2021
8am- 323mg/dl
10am- 259 mg/ dl
1pm- 251mg/ dl
3pm- 245 mg /dl
7pm -245 mg/ dl
*From 20th March to 23rd march
Patient is on insulin
Breakfast-3 idli+Java
Lunch-3 chapathi
Dinner-java+fruits
•22/3/2022
8am -310 mg /dl
10am - 277mg/ dl
*From 24th to 25th march
Before breakfast and dinner-glimiperide 3 mg
After breakfast and dinner-metformin 500mg
Breakfast-3 idli+ Java
Lunch-3 chapathi
Dinner-fruits+java
•24/3/2022
4 am- 171 mg/dl
7am -341 mg/dl
10am- 250 mg/dl
11am -166 mg/dl
3pm- 341 mg/dl
•25/ 3 /2022
4am -171g/dl
7am -341 mg/dl
1pm- 209 mg/dl
7pm -166 mg/dl
10 pm- 209mg/dl
*From 26th to 29th march
Before breakfast and dinner-glimiperide 4 mg and 3 mg respectively
After breakfast and dinner-metformin 500 mg
Breakfast-idli+java
Lunch-1 cup of rice
Dinner-fruits+java
•26/ 3/2022
7am - 166 mg/dl
10am- 304 mg/dl
3pm- 296mg/dl
7 pm -201mg/dl
10pm- 269mg/dl
•27/ 3/ 2022
6 am- 271 mg/dl
8am- 169 mg/dl
10am-- 306 mg/dl
2pm- 117 mg/dl
4 pm-311 mg/dl
8 pm-376 mg/dl
10pm-334 mg/dl
.28/3/2022
5 am-334 mg/dl
10.40 am-360 mg/dl
1 pm-245 mg/dl
4.40 pm-362 mg/dl
8 pm-225 mg/dl
10.22 pm-232 mg/dl
.29/3/2022
6.30 am-179 mg/dl
11.27am-282 mg/dl
1.30 pm-212 mg/dl
4.30 pm-320 mg/dl
8 pm -259mg/dl
11pm-301mg/dl
30/3/2022
6.30 am 176 mg /dl
.jpeg)
.jpeg)
Comments
Post a Comment