NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. A
54 yr old male, govt service employee by occupation, resident of west bengal, came for regular checkup
Patient was apparently asymptomatic until
25yrs ago them he had symptoms of headache, giddiness, for which he went to a doctor and was diagnosed with hypertension, once medications were started, bp came under control
In 2000, he stopped medication for 15-20 days
again he c/o lightheadedness, neck stiffness, and his tongue was rolling backward (tongue spasm). After this happened 2-3 times, he was hospitalized for 1 day.
16yrs ago, at the age of 38, he had wt loss and on general checkup, found out his sugar levels were high and was diagnosed with diabetes
7 yrs ago, while on a routine checkup, his BP was found to be 140/90 mmHg. It was not coming down even on changing medications. Then Dr. increased dosage to b.d from o.d, after which his BP came within 130-120/80-82.
Pt had lost 10 kg body wt in past 10 yrs.
No h/o chest pain, sweating, palpitations, sob, orthopnea, paroxysmal nocturnal dyspnea, cough, burning micturation, loose stools, nausea or vomitings
Past history:
K/c/o hypertension since 25 yrs and diabetes mellitus type 2 since 17 yrs
Not k/c/o epilepsy, asthma, tb, cad, cva
Personal history:
Appetite normal
Diet mixed
Bowel and bladder normal
No known allergies
Addition: Pt started smoking at age of 25 yrs. Smoking on an average of 10 cigarettes/day. Sometimes, 2-3 more sometimes 2-3 less
Family history: Father - CVD, died after a brain stroke
Mother - DM detected at a later stage of life
Sister - HTN
General examination:
No palor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Vitals:
Bp: 140/90 mmhg
Rr: 16cpm
Pr: 86bpm
Spo2: 98%at ra
Grbs: 109mg/dl
Systemic examination:
CVS: s1, s2 heard
RS: bilateral air entry present, normal vesicular breath sounds heard
P/A: soft, non tender, bowel sounds heard
CNS:
Sensory examination normal
Motor examination normal
Reflexes normal
Investigations:
Hba1c 6.8%
Plbs: 136 mg/dl
Sr creatinine: 1.4mg/dl
Treatment given:
1.T. EMPAGLIFLOZONE 12.5MG AND METFORMIN 500MG PO OD AT 8AM
2.T SITAGLIPTIN PHOSPHATE AMD METFORMIN HYDROCHLORIDE 50/500MG PO BD AT 8 AM AND 8PM
3. T RIPAGLINIDE 1MG PO OD AT 2PM
4. T MEPOPROLOL SUCCINATE 50MG AND AMLODIPINE 5MG PO BD AT 8 AM AND 8 PM
5. T. OLMESARTAN 40MG PO BD AT 8 AM AND 8 PM
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