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
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