58YEAR OLD MALE PATIENT

 September 22,2022



 "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 inputs on the comment box





58 year old male patient came to the GM OPD with cheif complaints of

-tingling and burning sensation in both soles since 1 year

-decreased eyesigh(right eye) since 2 months



HISTORY OF PRESENT ILLNESS

He is farmer.he used to wake up at 6 am in the morning and returns home by 5 pm and sleeps at 9 pm 

 patient was apparently asymptomatic 10 years back.Then he developped pain and burning sensation during micturition and decreased urine output,for which he went to a local hospital and he was told that he have kidney disease and medication wa given.Hi symptoms were resolved initially but later symptoms were on and off. He was diagnosed with Type 2 DM 3 years back.He is on medication(glimiperide and metformin)since 3 years.patient also developped backpain since 3 years.Patient also developped burning and tingling sensation in both soles since 1 year.His eyesight(right eye)decreased since 2 months.


PAST HISTORY

-B/L knee pain since 20 years

-K/C/O kidney disease since 10 years

-K/C/O Type2 DM since 3 years(on medication(GLUCORYL-M1-glimiperide and metformin)

-N/K/C/O-Asthma,Epilepsy,BP,Thyroid,CVA,CAD


PERSONAL HISTORY

Appetite-normal

Diet-mixed

Bowel and bladder movements-regular

Sleep-adequate

Alcohol-stopped since 20 years

Smoking-no


FAMILY HISTORY

His brother is diabetic since 5 years


GENERAL EXAMINATION

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Edema-absent


VITALS

BP-100/80mmHg

PR-84bpm

RR-20cpm

TEMP-98.5°F

SPO2-99% at RA

GRBS-150mg/dl


SYSTEMIC EXAMINATION

=>CVS

S1S2+

No thrills

No murmurs

=>R/S

BAE+

NVBS-heard

Dyspnoea-absent

Wheeze-absent

No adventitious sounds heard


=>P/A

Soft,nontender

Shape of the abdomen-scaphoid

No palpable mass present

Hernial orifices-normal

No free fluid

Liver-not palpable

Spleen-not palpable

Bowel sounds-heard


=>CNS

patient is conscious coherent and cooperative

Speech-normal

No signs of meningeal irritation

NFND


PROVISIONAL DIAGNOSIS

TYPE2 DM WITH PERIPHERAL NEUROPATHY


INVESTIGATIONS

22/09/2022
















TREATMENT

1)TAB.GLIPIZIDE 3MG PO/OD

2)TAB.GABENTIN 100MG PO/HS












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