55yr old female

This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome

Name: K.G. Prasuna Reddy
Roll no. 59

I've 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 a diagnosis and treatment plan.



Following is the view of my case

55YR OLD SHOPKEEPER CAME WITH C/O BURNING MICTURATION SINCE 3 DAYS

PT WAS APPARENTLY ASYMPTOMATIC 10 YRS BACK THEN SHE COMPLAINED OF GENERALIZED WEAKNESS AND GIDDINESS FOR WHICH SHE WENT TO LOCAL HOSPITAL WHERE HER GRBS WAS 500MG/DL. SHE WAS DIAGNOSED WITH PTB WITH DM2 AND WAS PUT ON OHAS
SINCE 4 MONTHS, SHE IS COMPLAINING OF BURNING SENSATION IN BOTH FEET, PRICKING TYPE, RELIEVING ON MEDICATION.
C/O COUGH SINCE 2 MONTHS
DRY TYPE
NO SOB, ORTHOPNEA
PND+
SINCE 2 DAYS, PT COMPLAINED OF 1 EPISODE OF VOMITING, AFTER FOOD, NON PROJECTILE TYPE, WITH FOOD AS CONTENT
C/O NAUSEA+
NO C/O ABDOMINAL PAIN, LOOSE STOOLS
NO H/O COLD, FEVER, CHEST PAIN, PALPITATIONS, SYNCOPAL ATTACKS
H/O WHEEZE DURING NIGHT +

PAST H/O:
K/C/O HTN SINCE 6YRS
NOT K/C/O ASTHMA, EPILEPSY, CVA  CAD

PERSONAL H/O:
APPETITE NORMAL
DIET MIXED
SLEEP ADEQUATE
BURNING MICTURATION
BOWEL HABITS NORMAL
NO ADDICTIONS
NO KNOWN ALLERGIES

NO KNOWN ALLERGIES

FAMILY H/O:
SIMILAR HISTORY IN HER GRANDFATHER

MENSTRUAL H/O:
ATTAINED MENOPAUSE AT 48Y

GENERAL EXAMINATION:
MODERATELY BUILT AND NOURISHED
PALOR: MILD

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA 


VITALS AT ADMISSION:
BP: 140/70MMHG
PR: 100BPM
RR: 14CPM
TEMP: 98.6F
SPO2: 98% AT RA
GRBS: 187MG/DL

SYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD 
RS: BAE PRESENT 
P/A: SOFT, NON-TENDER 
CNS: HMF INTACT 



PROVISIONAL DIAGNOSIS:
UTI WITH DM2 WITH H/O PTB 10 YRS BACK

INVESTIGATIONS:
TREATMENT:
22/12/22

1. TAB PREGABA M 75MG PO HS
2. TAB PAN 40MG PO OD
3. TAB TELMA 40MG PO OD
4. TAB GLIMI M1 PO OD
5. INJ ZOFER 4MG IV STAT
6. TAB ZOFER 4MG PO TID
7. TAB ULTRACET PO BD

23/12/22
1. TAB PREGABA M 75MG PO HS
2. TAB PAN 40MG PO OD
3. TAB TELMA 40MG PO OD
4. TAB GLIMI M1 PO OD
6. TAB ZOFER 4MG PO TID
7. TAB ULTRACET PO BD

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