55 year old female with Uncontrolled Glucose levels.

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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 55 year old female , daily labourer by occupation resident of Suryapet came for insulin dose fixation for eye surgery.She is a known case of Diabetes.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 years ago.She had giddiness, shortness of breath ,frequent passage of urine ,increase in thirst and was diagnosed with Diabetes Mellitus (type 2 ) at kamineni hospital in cherlapally at the age of 53.

Diminishing of vision in left eye since 6 months and was posted for cataract surgery but due to high uncontrolled sugar levels ,it was postponed.

H/o vomiting 4 times /day (4 days)2 years ago subsided with insulin intake 2 times/day .

No H/o loss of sensation in  limbs.(upper and lower)

No H/o tingling sensation in limbs.

No H/o swelling in ankles ,feet, hands and legs.

PAST HISTORY

Diabetes Mellitus since 2 years.

No H/o Hypertension, Tuberculosis,Asthma, Thyroid disorders

PERSONAL HISTORY

Appetite-Normal

Diet-Mixed diet

Bowel and Bladder movements- Regular

No H/o allergies

No addictions

FAMILY HISTORY

Elder brother is  a known case of Diabetes

TREATMENT HISTORY

Metformin -500mg BD

Inj.Mixtard 20U M,20 UN ( 2times /day)

GENERAL EXAMINATION

On examination, patient is conscious, coherent, cooperative

Patient is moderately nourished

No pallor,icterus, cyanosis, clubbing, lymphadenopathy, edema

Vitals

Temperature- afebrile

Pulse rate -79/min

Respiration rate-18/min

BP-110/70mm/Hg

SYSTEMIC EXAMINATION

Cardiovascular system:

S1,S2 sounds heard.No murmurs

Respiratory system:

Bilateral air entry  present

Abdomen: soft and no tendernes

Central nervous system

Conscious, normal speech,all reflexes are normal.

Ophthalmology referral 

PROVISIONAL DIAGNOSIS 

Uncontrolled glucose levels.

TREATMENT 

1.GRBS charting regularly.

2.Inj.Human insulin s/c 

NPH -10 U (twice daily)

3.check for symptoms of hypoglycemia

4.Inj .25 D if GRBS shows <50mg/dl.