53 yr old female with uncontrolled diabetes

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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.

D. Shreeya , 8th sem ,roll no 39

CHIEF COMPLAINTS:

Fever since 6 days

Decreased appetite since 3days

Shortness of breath since 3 days

Vomiting since 2 days 

HOPI:

Patient is apparently asymptomatic 6 days ago there is an episode of fever 6 days back and relieved on medication and presented to OPD with chief complaints of decreased appetite since 3 days and vomiting since 2 days which is non projectile , food which is taken prior is the content of vomiting. There is shortness of breath since 3 days experiencing on rest.

PAST HISTORY

There is a past history 5 yr back of decreased urine output and burning micturation, swelling of both limbs and decreased appetite and vomiting  and admitted in the hospital and symptoms subsided on given medication.

Had a History of chest pain 15yr back

Patient is a known case of diabetes and hypertension since 30 years and on medication regularly.last 18 yrs she is on insulin 

Hypothyroid since 5 yrs

PERSONAL HISTORY:

She is a housewife 

She wakes up in the morning 8 am and have tea then at 10 am breakfast (oats)and then lunch at 3 pm and dinner at 8 pm and goes to sleep by 10pm

Diet: mixed

Appetite: decreased

Sleep: adequate

Bowel and bladder: regular

Has a habit of taking betel leaf since 15 yrs

No History of allergy 

GENERAL EXAMINATION:

Patient is conscious coherent and we'll orientated to time place and person.

Vitals: 

Pulse- 80bpm

RR - 24cpm

BP - 130/70 mmHg

SpO2 - 96%

Systamic examination 

CVS - S1 S2 +

RS - BAE+

P/A - soft and non tender

There is pallor.

Edema of bilateral  lower limbs

ECG

CBP

USG

X RAY

GRBS CHARTING

15/08/22

10pm - 320

16/08/22

12am- 192

8am- 103

1pm- 230

3pm- 208

7pm- 203 

17/08/22

12am- 177

8am- 157 

10am- 189 

2pm- 124 

7pm - 267 

10pm- 179 

18/08/22

8am - 273 

2pm- 248 

7pm - 319 

TREATMENT:

1) Normal soft diabetic diet

2) IVF - NS + RL - 75ml/hr

3) inj. HAI according to GRBS

4) inj. OPTINEURON 1amp in 100ml NS

5) inj. ZOFER 4mg/IV/BD

6) inj. LASIX 20mg/IV/BD

7) tab. MET-XL 25mg/PO/OD

GRBS monitoring 

PROVISIONAL DIAGNOSIS:

UNCONTROLLED SUGARS SECONDARY TO TYPE 2 DIABETES MELLITUS