A 70 year old male came for regular checkup for type 2- diabetes mellitus
MAY 20th 2024
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here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.
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I have Been given this case to solve in an attempt to understand the topic of "patient clinical data analysis"to develop my competency and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.
CASE
A 70 year old patient came for regular checkup of type 2 diabetes mellitus
HISTORY OF PRESENTING ILLNESS
PATIENT WAS APPARENTLY ALRIGHT 8 years BACK THEN HE DEVELOPED DIARRHOEA AND GOT TESTED FOR BLOOD SUGAR LEVEL AND FOUND TO BE DIABETIC. PATIENT STARTED ON MEDICATION SINCE THEN.
NO H/O TINGLING AND NUMBNESS.
NO H/O CHEST PAIN, CHEST TIGHTNESS.
NO SOB, OTHOPNEA, PND.
NO H/O FEVER, COLD, COUGH.
NO H/O BOWEL AND BLADDER ABNORMALITIES.
PAST HISTORY:
K/C/O DM TYPE-2 SINCE 8 years ON METFORMIN-500 MG
N/K/C/O HTN, CVA, CAD,TB, THYROID DISORDERS.
PERSONAL HISTORY:
DIET: MIXED
BOWEL MOVEMENTS: REGULAR
NO KNOWN ALLERGIES
OCCASIONAL DRINKER SINCE 8 YEARS
STOPPED SMOKING 50 YEARS BACK.
FAMILY HISTORY:
NOT SIGNIFICANT.
GENERAL EXAMINATION:
PATIENT CONSCIOUS/ COHERENT/ COOPERATIVE.
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, GENERALISED LYMPHADENOPATHY, EDEMA OF FEET.
TEMP: AFEBRILE.
PULSE RATE: 82 BPM
RR: 20 CPM
BP: 100/70 MMHG
SPO2: 98@ RA
GRBS: 574 MG%
SYSTEMIC EXAMINATION:
CVS: S1 S 2 HEARD. NO MURMURS.
RESPIRATORY SYSTEM: TRACHE-CENTRAL
BAE+
P/A: SOFT, NON-TENDER
CNS: NO FOCAL NEUROLOGICAL DEFECTS
REFLEXES-RT LT
BICEPS ++. ++
TRICEPS ++ ++
SUPINATOR + +
KNEE ++ ++
ANKLE + +
OPHTHALMOLOGY REFERRAL ON 18/5/24 I/V/O FUNDOSCOPIC EXAMINATION
IMPRESSION- NO EVIDENCE OF DIABETIC RETINOPATHY IN BOTH
COURSE IN THE HOSPITAL-
A 70 YEAR OLD MALE CAME FOR REGULAR CHECK UP FOR TYPE 2 DIABETES MELLITUS.
ALL THE NECESSARY INVESTIGATIONS WHERE SENT.
DIAGNOSED AS UNCONTROLLED SUGARS WITH TYPE 2 DIABETES MELLITUS.
OPHTHALMOLOGY REFERRAL ON 18/5/24 I/V/O FUNDOSCOPIC EXAMINATION
IMPRESSION- NO EVIDENCE OF DIABETIC RETINOPATHY IN BOTH EYES.
INVESTIGATIONS:
CHEST X RAY-
2 D ECHO-
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