55 year old female with Uncontrolled Glucose levels.

 

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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 55 year old female , daily labourer by occupation resident of Suryapet came for insulin dose fixation for eye surgery.She is a known case of Diabetes.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 years ago. On one fine day while she was doing her household work she had giddiness which lasted for a while and has been taken to a nearby hospital ,blood and urine investigations were done.She gave a history of increased frequency of urine since 1month.

No H/o nocturia , burning micturition.

H/o generalised weakness since 15 days .

H/o increased thirst (polydipsia) since 1 week .

H/o vomitings 4 days ago (3 times/ day ) food as content,non projectile in nature,non blood stained . 

No h/o loose stools,blood in stools.

No h/o fever ,rash, abdominal pain.

No h/o palpitations, sweating.

2 years ago she was diagnosed with diabetes mellitus at the near by hospital and was on medication since then.(Tab .Metformin 500 mg

On the date of admission, 

Diminishing of vision since 6 months in the left eye and was posted for surgery ,but her glucose levels were abnormal so referred for control of glucose levels to bring down to normal levels .

No H/o loss of sensation in  limbs.(upper and lower)

No H/o tingling sensation in limbs.

No H/o swelling in ankles ,feet, hands and legs.

PAST HISTORY

Diabetes Mellitus since 2 years.(on medication)

No H/o Hypertension, Tuberculosis,Asthma, Thyroid disorders

PERSONAL HISTORY

Appetite-Normal

Diet-Mixed diet

Bowel and Bladder movements- Regular

No H/o allergies

No addictions

FAMILY HISTORY

Elder brother is  a known case of Diabetes

TREATMENT HISTORY

Metformin -500mg BD

Inj.Mixtard 20U M,20 UN ( 2times /day)

GENERAL EXAMINATION

On examination, patient is conscious, coherent, cooperative

Patient is moderately nourished

No pallor,icterus, cyanosis, clubbing, lymphadenopathy, edema

Vitals

Temperature- afebrile

Pulse rate -79/min

Respiration rate-18/min

BP-110/70mm/Hg

SYSTEMIC EXAMINATION 

Cardio vascular examination:

 No visible pulsations, scars, engorged veins. No rise in jvp 

 Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

  S1 S2 heard . No murmurs.

Respiratory system

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical

Bilateral Airway Entry - positive

Normal vesicular breath sounds heard

CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.

On 9/11/2021

Ophthalmology referral 

Investigations

1.GRBS charting regularly

Before breakfast

After breakfast

Before lunch

After lunch 

Before dinner

After dinner.

PROVISIONAL DIAGNOSIS 

Uncontrolled glucose levels.

TREATMENT 

1.GRBS charting regularly.

2.Inj.Human insulin s/c 

NPH -10 U (twice daily)

3.check for symptoms of hypoglycemia

4.Inj .25 D if GRBS shows <50mg/dl.