uncontrolled diabetes with anemia

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 comments on 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 prognosis

A 35yr old Male resident of West Bengal came to causality with chief complaints of loss of appetite and loss of weight since 1 month.

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐑𝐄𝐒𝐄𝐍𝐓𝐈𝐍𝐆 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

Patient was apparently asymptomatic 1 month ago then developed loss of appetite to solid foods associated with nausea and vomiting which occures 2-3hrs after intake of food, sudden in onset, containing food particles, not blood stained, no foul smell

Not associated with stomach pain.

Patient complaints of gradual loss of weight since 1 month (dropped 28kgs in 1 month) which is associated with malaise, fever which is insidious in onset, low grade fever, relieved on medication.

No h/o of cough, evening rise of temperature, chest pain

No h/o of blood in vomitus, blood in stools, pain in abdomen.

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐀𝐒𝐓 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

Patient was diagnosed with diabetes 4 months ago while he was recieving treatment for chicken pox. 

Not k/c/o HTN, TB, ASTHMA, EPILEPSY.

Family history:- not significant

𝐏𝐄𝐑𝐒𝐎𝐍𝐀𝐋 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-

Appetite:- lost

Diet:- mixed

Sleep :- inadequate

Bowel and bladder movements:- regular

 

 No drug allergies present

 No addictions

No tobacco smoking and chewing.

General examination:- 

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

Moderately built, moderately nourished

Pallor:- present

Icterus:- absent 

Cyanosis:- absent 

Clubbing:- absent

Generalized lymphadenopathy:- absent

Bilateral pedal edema :- absent

O/E :

Temp:- 101 F

PR- 72 bpm

BP- 130/90 mm of Hg

Spo2-100% at room air

RR : 16 cpm

GRBS- 

Respiratory system examination :

Normal vesicular breath sounds heard

On abdominal examination:

Inspection:

Shape of abdomen is scaphoid 

Flanks are free

Umblicus is in position, inverted

Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.

No visible veins.

No engorged veins.

Movements of abdominal wall are normal, no visible gaatric peristalsis 

Palpation: 

Liver examination:

On superficial palpation

no tenderness , raised temperature

On deep palpation

 No tenderness in liver

Non pulsatile

Spleen examination: 

No tenderness and pain

Percussion :

No fluid thrill.

No shifting dullness.

Percussion of Liver for Liver Span : 10cm

 

Auscultation 

Normal bowel sounds heard.

2. Bruit - no renal artery bruit heard.

                no iliac artery bruit heard.

CVS Examination :

Inspection :

No abnormal palsations

No visible scars.

No chest deformities.

Mediastinum normal

Trachea central in position.

Palpation :

Mediastinal position : apex beat normal

                                       Position of trachea central.

Percussion :

On percussion No cardiomegaly.

Ascultation : on examination of mitral area, pulmonary area, tricuspid area and aortic area S1 and S2 heard. No murmurs heard.

CNS : NAD

INVESTIGATIONS

Complete blood picture 

Liver function test

Renal function test

Random blood sugar

Provisional diagnosis :

 Uncontrolled diabetes with anemia

Treatment :