65 year old Female with Uncontrolled sugars

65 year old Female with Uncontrolled sugars
July 25, 2023

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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box are welcome.

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.

Chief complaints
A 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

History of Present Illness
Pateint was apparently asymptomatic 3 days back then she developed fever high grade intermittent, associated with chills and rigors associated with body pains and weakness
Patient was taken to near by hospital and was found to have high sugars and treated conservatively
Patient also complaint about SOB since 3 days which is grade 2-3, increased on lying down and relieved by sitting
No c/o chest pain, palpitations,PND
Normal urine output
No c/o pedal edema, facial puffiness
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 yr 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

TELMA 40 MG
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 type 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

Diet - Mixed
Appetite- Decreased 
Sleep - Adequate 
Bowel & bladder movements - Normal        Addictions - No addictions

FAMILY HISTORY
Not significant

SURGICAL HISTORY
Abdominal Hysterectomy 25 YEARS AGO

General Examination 
Patient is conscious,coherent,cooperative well known with time, place, person 
Well built and moderately nourish
Pallor present 
Icterus: Absent 
Cyanosis: Absent 
Clubbing: Absent 
Lymphadenopathy: Absent 

VITALS

Temperature:97.2F
PR:80bpm
RR:17cpm
BP:130/80
SPO2: 97% 

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM
Patient examined in sitting position

Inspection :
Upper respiratory tract - oral cavity, nose & oropharynx appear normal
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type
Trachea central in position & Nipples are in 5th Intercoastal space
No dilated veins,sinuses, visible pulsations.

Palpation :
All inspiratory findings confirmed
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line
Infraclavicular- (NVBS) (NVBS)
Mammary- (NVBS) (CREPTS)
Axillary- (NVBS) (NVBS)
Infra axillary-(NVBS) (CREPTS)                 
Suprascapular- (NVBS) (NVBS)
Interscapular- (NVBS) (NVBS)
Infrascapular- (NVBS)(NVBS)

CVS

Inspection : 
Shape of chest- elliptical 
No engorged veins, scars, visible pulsations
Palpation :
Apex beat-palpable in 5th inter costal space
Auscultation : 
S1,S2 are heard
No murmurs

PER ABDOMEN
Shape of abdomen-scaphoid
Tenderness-No
Palpable mass-No
Liver- Not palpable
Spleen - Not palpable
Bowel sounds- Normal

CNS

Tone - UL   LL

Rt. Normal Normal

Lt. Normal  Normal

Power of right and left UL and LL is 
5/5 and 4/5
Reflexes B T. S. K. A. plantar

          Lt: 2+. 2+. +. 3+. -.M

          Rt: 2+. 2+. +. 3+. -. M
Investigations :
Chest X Ray
USG
Provisional Daignosis :

**Uncontrolled sugars withk/c/o DM 2 since 4 yrs& HTN since 1 yr
**CVA Left Hempiparesis since 1 yr

Treatment plan
1.HAI 6 UNITS IV STAT
2.HAI INFUSION @6ML/HR
3.IV FLUIDS NS @100 ML/HR
4.INJ PAN 40MG IV/OD
5.TAB ECOSPRIN AV 75/10 PO/HS




















 








 








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