74/M with uncontrolled sugars with headache

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 is 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.


A 74 year old male came to OPD with

c/o of general body pains since 5 years

c/o of deviation of mouth to Right side since 4 years

 c/o of headche since 15 days.

HOPI:

Pt was apparently asymptomatic 15 days back then she developed headache which is lasting for entire day.photophobia present,phonophobia present,not associated with nausea vomiting,giddiness.

he had a chief complaints of deviation of mouth to Right side since 4 years.It is associated with drooling of saliva/liquids.

he has a chief complaints of general body pains since 5 years.

Past history:

k/c/o DM Type 2 since 10-15 years now using HAI 6U TID.NPH 6U BD

K/c/o HTN since 10 years using TAB.AMLO 5MG OD

k/c/o CVA since 4 years using TAB.ECOSPRIN-AV 75/10 PO/HS

Not a k/c/o Tb,epilepsy,cva,cad,thyroid

Personal History -

Married

Occupation- Farmer

Diet: mixed

Appetite: normal

Bowel and bladder : Normal

Addictions:occasional alcoholic(stopped 5 years back)

Smoker(stopped 5 years back)


Family History -

No similar complaints in the family. 


General Examination -

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

She is conscious, coherent andcooperative.

Built & nourishment-Moderate

No pallor 

No cyanosis

No icterus

No clubbing

No edema

No lymphadenopathy.





Systemic examination:

CVS : 

S1 S2 present

No murmurs


RESPIRATORY SYSTEM;

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard


ABDOMEN:

Shape of abdomen: scaphoid.

Soft, non tender, no organomegaly present.

No rigidity or guarding.


CNS :

Patient is conscious

Speech-normal 

Signs of meningial irritation

Neck stiffness- negative

Kernings sign-negative

Cranial nerves-intact

Motor system:

Power:

          UL LL

R 5/5. 5/5

L 4/5. 4/5

 

Tone:

            R. L

UL. Normal. Normal

LL. Normal normal

Sensory system: normal

Reflexes:

           Knee. Ankle. Biceps. Triceps supinator

Right -. -. 2+ - -

Left. -. -. 2+ 2+ -

Plantar flexion seen.

No cerebellar signs 


PROVISIONAL DIAGNOSIS:

Uncontrolled sugars with type 2 DM with HTN with CVA

TREATMENT:

.IV FLUIDS NS@75ML/HR

2.INJ.PIPTAZ 2.25GM IV/TID

3.INJ.HUMAN ACTRAPID INSULIN S/C TID BEFORE MEALS 

4.INJ.ZOFER 4 MG /IV/BD

5.TAB.CINOD 10MG PO/BD

6.INJ.PAN 40MG/IV/OD

7.TAB.ECOSPRIN-AV 75/10 PO/HS 

8.TAB.NAPROXEN 250MG PO/BD

9.STRICT I/O CHARTING

10.BP,PR,TEMP MONITORIMG 4TH HOURLY

11.GRBS 7 POINT PROFILE



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