GM case-4

August 22,2022
Case scenario.......

Hi, I am P.kathyayani, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:

Chief complaints:
A 65 year woman with fever associated with chills and rigors since 1 week,high grade fever.
Bilateral lowerlimb weakness and difficulty in walking since 3 days.
Patient is housewife by occupation and husband expired 5 years ago.
Patient was asymptomatic for 10 years due to decreased appetite  visited local hospital and diagonesed as Type 2 diabetes since then she is on medication with Oral Hypoglycemic agents(OHAs).




HISTORY OF PRESENT ILLNESS:
Since 1 week she is having high grade fever associated with chills and rigors,loss of appetite and missed OHAs since 2 days.
Difficulty in walking, bilateral lowerlimb weakness due to this she was passing stools and urine in clothes since 2 days.



ASSOCIATED DISEASE:
Not associated with asthma, hypertension, coronary artery disease (CAD).





PAST HISTORY:
Hyperthyroidism since 20 years 
Type 2 Diabetes mellitus since 10 years




PERSONAL HISTORY:
Married
Diet:mixed
Occupation:housewife
Appetite:Lost
Bowels:Regular
Micturition:Normal
Allergies:no
Addictions:Alcohol regularly



FAMILY HISTORY:Nil



DRUG HISTORY:
On Medication for hyperthyroidism-
5 mg polon
T.Neomereazole 
And OHAs for diabetes



GENERAL EXAMINATION:
Pallor:No
Cyanosis:No
Lymphadenopathy:No
Clubbing of finger:No
Icterus:No
Oedema of feet:No




Vitals:

Temperature: 98.6C/F

Pulse: 89beats per minute

Respiratory rate: 16 cycles per minute

Blood pressure: 120/80mm of Hg

SPO2: 98%
GRBS:102mg%
SYSTEMIC EXAMINATION:

Cardiovascular system:


thrills:no
murumurs:no
Cardiac sounds: S1, S2 

Respiratory system:
dyspnea:no
wheezing:no
Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid 
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds:no

Central Nervous System:

Level of consciousness:Conscious

Speech: normal

INVESTIGATIONS:
   

PROVISIONAL DIAGNOSIS:
Diabetic ketoacidosis 

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