Type 2 Diabetes mellitus case

 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

October 20,2022

CHIEF COMPLAINT
Patient came to casualty with 
C/O Backpain and neck pain since 6 years
K/C/O DM SINCE 6 years
K/C/O HTN SINCE 2 years 

HOPI

-->Patient was apparently asymptomatic  
then she had a c/o polyuria 6yrs back then got on routine investigation , then she was diagnosed with type 2 diabetes mellitus 6 yrs back.
-->She is suffering from neck pain (on/off , persistent , radiating to shoulders ) and headache (diffuse type)  since 6 years.
-->She is also suffering from  low back pain (only when she is sitting for longer period)
On/off non radiating type  since 2-3 yrs.
-->She has h/o pain in right hypochondrium (on/off) since 3 yrs with a recent episode 2-3 days back .
 -->k/c/o HTN  since 2yrs but not on any regular medication.

PAST HISTORY

Not a k/c/o CAD/Epilepsy/TB/Asthma/thyroid disorders

PERSONAL HISTORY

Diet - mixed 

Appetite - decreased since one month 

Bowel movements: regular 

 Bladder movements : decreased 

Sleep : adequate

No addictions and allergies 

 FAMILY HISTORY : insignificant 

GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

-No malnutrition

-No dehydration 

 ▪️VITALS:
Temperature - afebrile
Pulse rate - 86 bpm
Respiration rate - 12cpm
BP - 120/80 mmhg
GRBS -268mg%

SYSTEMIC EXAMINATION:
• CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

•RESPIRATORY SYSTEM 
No Dysponea
No Wheeze 
Position of trachea central
Vesicular beath sounds

• Abdomen
Shape of abdomen': schaphoid
Tenderness: no
Palpable mass': no
Hernial orifices :no
Free fluids: no
Bruits: no
Liver: no
Spleen: no 
Bowel sounds: no

• CNS
Level of consciousness :consious
Speech: normal
Signs of meningial inflammation
Neck stiffness: no
Kerning sign :no

INVESTIGATIONS

Provisional diagnosis:
Type 2 diabetes mellitus

Treatment:
Tab Glimiperide 2.5 mg Po/BD
(Before food)
 Tab Metformin 1000mg Po/BD
 (After food)
 




 






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