GENERAL MEDICINE- Blog3

A 60 year old woman with loss of appetite and vomiting.

Hi, I am Mucha Sainath Reddy  , 3rd Sem Medical Student.This is an 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 patient's 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 the comment box is welcome.”

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. 

 A 60 year old woman from nalgonda, who is house wife  came to OPD with the chief complaint of-

Decreased appetite since 3 days

Vomiting(whatever she consumed) since 2 days

Fever since 6 days

Shortness of breath since 3 days

History of present illness-

She has been complaining with decreased appetite, vomiting and fever since 6 months which increased during nights and lasts for 6-8 days and relieved on medication.

She has been previously admitted here 6-8 months ago with a complaint of fever and discharged after attaining normal temperature on medication.

Past illness-

She was also diagnosed with renal failure 3 years ago

She has been diagnosed 20 years ago with type-2 DM for which she takes insulin injection and with Hypertension.

Personal History-

Diet: mixed

Appetite: decreased 

Sleep: hypersomnia

Bowel: irregular(once in 8-10days since 6 months)

Bladder: frequent urination(polyuria) and incontinence 

Addictions: pan 

Family History-

No significant family history 

General Examination:

Patient was conscious coherent and cooperative

Pallor - present 

No Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy

Vitals-

Pulse: 72bpm

GRBS : 128mg/dl @4.30pm

Provisional Diagnosis-

Uncontrolled Type2 Diabetes Mellitus