Bhavya's Elog

 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.

CASE DISCUSSION:

 A 63 yr old male from Narketpally was brought by his attender (wife) to the hospital with chief complaints of increased frequency of urination since 10days and easy fatiguability since 1week and increased sugar levels since 4days

 

HISTORY OF PRESENTING ILLNESS:

          Patient was apparently asymptomatic 10 days back,then developed increased frequency of micturition

It was not associated with burning micturition,urgency

          Later since 7days he developed easy fatiguabilty (during normal daily works only)

  

NEGATIVE HISTORY:

      No H/O of:

               Polydipsia

               Tingling

               Numbness

               Pedal Edema

               Decreased urine output

               Blurred vision

               Dizziness

               Shortness of breath

               Fever

               Chest pain

PAST HISTORY:

     K/C/O of DM type 2 since 15years.It was discovered when he went to hospital for wart excision.He took Tenigliptin 20mg + Metformin 500mg.He is shifted to Insulin Mixtard(4IU,8IU) a week ago.

     K/C/O of Hypertension since 10years.It was discovered when he went for sugar level checkup.He is taking Telmisartan 40mg + Amlodipine 5mg

     K/C/O of Asthma since 4years.He developed difficulty in breathing in the early morning.He is taking Budesonide nebulization since then.

   He has a history of fall on left wrist 8years back for which he took home treatment (pasaru kattu) and fall on back 8months back which resulted in fracture of lumbar vertebra (L2,L3,L4),Which was treated with bed rest for 2months back,waist belt.

   Before admission here he took medication for polyuria with Oxybutynin 5mg+ Tamsulosin 0.4mg+Dutasteride 0.5mg

    No H/O of Epilepsy,TB,CVA,CHD,Chronic kidney problems.

PERSONAL HISTORY:

        

           His appetite was normal and takes mixed diet, sleep adequate, bowel and bladder movements were regular. Occasional alcoholic and beedi smoker (18 per day) since 30 yrs,8months back .

General examination:Patient is conscious, coherent, co-operative ,oriented to place,time,person,moderately built and moderately nourished. Comfortable . 

        Pallor - Negative

        Icterus- negative

        No Cyanosis ,

              Clubbing,

              Lymphademopathy,

              Pedal edema.

 Patient has hypopigmented macules over upper limb,lower limb,lower back,chest.He gave the explanation of him being a cook for 20years ...those are spilled oil marks.

 

        VITALS:

    Bp: 120/90 mmhg

    Pr :80bpm

    Spo2 :98%at room air

    temp :97°F

    RR -15cpm

   Grbs -240gm/dl

   Cvs -S1,S2 heard,no murmurs

   Rs -Bae +,NVBS heard

   P/a: soft ,nontender,bowels sound heard.