Type 2 diabetes case

 This is online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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.

A 56 year old female came to opd for regular checkups of diabetes.

Chief complaints : 

dizziness, associated with palpitations and bilateral lower limb numbness since 6 days.

History of presenting illness :

Patient was apparently asymptomatic 12 years back,then she diagnosed with diabetes mellitus. She also suffered with seizures .since 4 days ,she has constipation and passes stools 3-4 days since 1 year . Also complaints of headache posteriorly,speech difficulties ,weight loss. No nausea , vomiting , burning micturition, diarrhoea .Dry teary eyes , pricking sensation in cornea since 6 days in left eye.

History of past illness:

Known case of diabetes since 12 years

Not a known case of tb , asthma , hypertension, thyroid, coronary artery disease.

History of 4 episodes of seizures before loosing consciousness in 2012,2017,Feb 2022, nov 2022

History of cataract surgery in left eye in 2020

History of hysterectomy in 1992, had half unit of blood transfusions.

Personal history :

Married

Appetite : normal      

Sleep: adequate 

Bowel and bladder: constipation 

Addictions : none 

Family history : 

No significant history 

Treatment history :

Since 2012 , she has taking insulin 

Blood transfusions done for hysterectomy in 1992 1/2 unit 

Cataract surgery done .

Mestrual history :

At 37 years of age she had undergone hysterectomy due to a benign tumor 

Two children , one abortion .

General examination :

Patient was conscious,coherent,cooperative,and well oriented to the time , place and person .

No pallor, icterus , cyanosis, clubbing , lymphadenopathy.

Vitals 

Grbs: 151mg/dl 

Pulse rate : 78 bpm

Temperature : afebrile

Gait : normal 

Systemic examination :

CVS : s1,s2 normal 

No Cardiac murmurs

Respiratory system: 

No dyspnea,wheeze 

Position of trachea- central 

Breath sounds - normal 

ABDOMEN 

Shape : scaphoid 

Tenderness : no 

Palpable : no 

Free fluid - no 

No distension

No pigmentation 

 Gall bladder distended 

Pancreas normal 

Spleen normal 11cm 

Urinary bladder distended 

Liver 

Spleen  not palpable 

Cns examination..... 

no focal neurological deficits 

Cranial nerves are intact 

INVESTIGATIONS:

Hemogram : 

Hb : 12.5

TLC: 9300

Platelets : 2.7 

Urine examination :

Colour : pale yellow 

Appearance - clear 

Sugar - present +++

Pus cells 4.5 

RBC - nil

Crystals - nil

Casts nil

Urine for ketone bodies - negative 

Liver function tests 

SGOT -13

SGPT -10

ALP - 162

Protein 6.6 

A/G 1.07 

Blood urea - 63 

Na+ 133

K+ 4.3

Cl - 101

Ca 2++ 0.98 

Serum creatinine - 1.0 

Urine protein / creatinine ratio 

Urine protein -4.0 

Urine creatinine - 32 

Ratio - 0.12 

GRBS 

10/12/2022

8.00 am    270 mg/dl 

12.00 am     299 mg/dl

2.00pm.     329 mg/dl

8.00 pm.   230 mg/dl

10 units HAI + 10 NPH given 

10.00 pm.  179 mg/ dl 

2.00 am.  155 mg / dl 

11/12/2022

208mg/ dl 

Provisional diagnosis :

Type 2 diabetes mellitus 

Treatment history : 

Conservative treatment 

N P H injection 

1.tab pregaba m  - 70mg /od

2.tab naproxen 250 mg 

3. Tab ecosprin 75 mg 

4. Tab atorva 20 mg 

5. Grbs 70 mg/dl maintain 

6. Inform sos .