supplm prefinal

CASE OF A 46 YEARS OLD MAN WITH TYPE 2 DIABETES MELLITUS.

This is an online e log book to discuss our patient's de-identified health data shared after taking his/her/guardians' signed informed consent. This Elog reflects my patient-centred online learning portfolio.

This is the case of a 46 yrs old man, who is a shopkeeper by profession and is a resident of West Bengal.

CHIEF COMPLAINT

The patient presented to the hospital with the chief complaints of

Chest pain from 12 years.

Generalised abdominal pain predominantly in the right and left flank regions and the lower abdomen from 12 years.

Pain in the fingers from 12 years.

Acidity from 10 years.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 12 years ago, 12 years ago he started experiencing chest pain, abdominal pain predominantly in the right and left flanks and the lower abdomen, and pain in the interphalangeal joints of the fingers. The pain was gradual in onset and increased progressively over the years. The pain was pricking in character and intermittent in nature with one episode of pain every hour. The pain was relieved by taking medication. The pain was not associated with fever, nausea or vomiting.

The patient has been experiencing epigastric pain for the past 10 years, for which he takes pantoprazole 40mg every day. Pain is relieved by taking the medication.

One year ago the patient started experiencing polyuria and polydipsia. On visiting the hospital he was diagnosed with type 2 diabetes mellitus. The patient is not taking any medication and does not have a regulated diet. One year ago the patient also started experiencing blurred vision which causes him headaches on reading.

HISTORY OF PAST ILLNESS 

The patient had a bout of pneumonia when he was a child, which caused him chest pain. He recovered after receiving treatment and the chest pain stopped.

He is a known case of Type 2 Diabetes mellitus from 1 year.

He is not a known case of hypertension, asthma, TB, Thyroid condition, CVD, or Epilepsy.

No history of blood transfusions.

FAMILY HISTORY

His father is a known case of Type 2 Diabetes mellitus.

PERSONAL HISTORY

DIET- Mixed diet

APPETITE- Decreased

SLEEP- Adequate

BOWEL AND BLADDER MOVEMENTS - Normal

ADDICTIONS-

ALCOHOL- From 5 years, consumes 1 glass a day.

SMOKING- Chronic smoker- 2-5 cigarettes /day

ALLERGIES- chicken and eggs cause dermatitis.

EXAMINATION

VITALS

BP- 100/80mmHg

PR- 70bpm

AFBRILE

GENERAL EXAMINATION

The patient is conscious, coherent and cooperative.

He is well built and well nourished.

Pallor- Absent

Icterus- Absent

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Koilonychia- Absent

Pedal oedema- Absent

SYSTEMIC EXAMINATION

PER ABDOMEN:-

INSPECTION- Shape of the abdomen- obese

The umbilicus is central and inverted 

No visible engorged veins, scars or sinuses

No visible pulsations

All quadrants are moving appropriately with respiration

No visible peristalsis

PALPATION-

Soft, mild tenderness at epigastric region 

Small mass in the epigastrium about 1 cm in size

No hepatomegaly 

No splenomegaly

PERCUSSION-

Liver dullness not obliterated

AUSCULTATION - 

bowel sounds heard 

CNS

The patient is conscious and coherent.

Speech is normal.

INVESTIGATIONS

3/9/2022

POST LUNCH BLOOD SUGAR

BLOOD UREA   

COMPLETE URINE EXAMINATION

HEMOGRAM

LIVER FUNCTION TEST

SERUM CREATININE

SERUM ELECTROLYTES

ECG

FASTING BLOOD SUGAR

5/9/2022

USG

6/9/2022

GLYCATED HEMOGLOBIN

6 MIN WALK TEST

XRAY ::

PA VIEW CHEST XRAY

PA VIEW ABDOMEN

PROVISIONAL DIAGNOSIS

Diabetes mellitus type 2

Non ulcer dyspepsia 

MANAGEMENT

3/9/2022

GRBS monitoring 6th hourly.

4/9/2022

GRBS monitoring 6th hourly.

5/9/2022

GRBS monitoring 6th hourly.

6/9/2022

1. TAB. Glimepiride 1mg PO/OD

2. TAB. Metformin 500mg PO/OD

3. GRBS Monitoring