70 year old male

 Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. 

A 70 year old male resident of motkur, farmer by occupation came with the chief complaints of polyuria, increased thirst since 20days.

 HISTORY OF PRESENT ILLNESS: 
Patient was apparently asymptomatic 10years back then he had complaints of polyuria,polydypsia, weakness for which he went to a local hospital and diagnosed to have diabetes mellitus (grbs approximately 400)for which he was started on oral hypoglycemics(K-GLIM-M 2mg), burning sensation in foot,blurred vision

HISTORY OF PAST ILLNESS:
Patient had undergone surgery for  gastric ulcers 20 years back and nasal polypectomy 6years back.

Not a known case of hypertension,asthama, epilepsy, tuberculosis.

DAILY ROUTINE:
Patient wakes up at 4am goes to the agricultural work ,at 10am he does his breakfast and dinner at 7pm

PERSONAL HISTORY:
Diet:mixed
Appetite:normal
Sleep: disturbed since 15days
Bowel and bladder:normal
Micturition:normal
Habits: consumes alcohol occasionally (not more than 90ml)
Stopped smoking 40yrs back

DRUG HISTORY:
no significant history 

FAMILY HISTORY:
No members of the family have similar complaints 

GENERAL EXAMINATION:
Patient was concious coherent cooperative and well oriented to time place and person.
No pallor,no cyanosis,icterus, clubbing generalized lymphadenopathy,no pedal edema .
VITALS:
Temperature: afebrile
PR:72bpm
RR:16cpm
BP:120/80mm hg
RBS:660mg/dl

SYSTEMIC EXAMINATION:
ABDOMEN:
INSPECTION:
Shape: scaphoid
Flanks:free
Umbilicus:inverted,central in position 
Normal hernial orrifices,no visible peristaltic waves,skin over umbilical region has scar 
PALPATION:
No tenderness,local rise of temperature 
PERCUSSION:
liver span:11.5cm
AUSCULTATION:
No bruit heard,bowel sounds heard

RESPIRATORY SYSTEM:
INSPECTION:
Chest is symmetrical
Trachea:central
No drooping of shoulders
No supraclavicular hollowing
No kyphoscoliosis
No use of accessory muscles for respiration
PALPATION:
Trachea:central
No intercoastal widening or narrowing
Chest movement: symmetrical
Measurement of chest expansion
Whole thorax:35.5cm
Hemi Thorax:17cm
AUSCULTATION:
Vesicular breath sounds
No wheeze

CVS:
S1 S2 heard
No thrills, murmurs
CNS:
Concious
Speech normal
Gait normal 
Sensory system normal
Motor system normal

Provisional diagnosis : uncontrolled sugars
Investigations:










Treatment:

INF-NS 70ml/hr
Tab.GLIM-M 1PO/OD
Tab.PREGABA-M 75mg PO/OD
Monitoring vitals
Final Diagnosis:type 2diabates mellitus 













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