GENERAL MEDICINE

GM-Case -1

February 13,2023

February13,2023

Case scenario....

  

Hi, I am akhila vallabineni, 3rd year bds 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 HISTORY:a 70 year old with high diabetic , hypertension 

E

CHIEF COMPLAINTS:high blood pressure ,sugar and with tremors which lead to mild brain stroke.

HISTORY OF PRESENT ILLNESS: patient apparently asymptomatic on year ago 

Cough since 15 days 

Breathless Ness since 10 days 

Fever since 5 days 

Cough with non blood stained more in nights 

Agrevative in supine position 

Chest pain 

Low grade fever with no chills

Intermittent 

PAST ILLNESS: 

Last year because of hyperglycemia  non Co operative sedation and felt unconscious for 2 days 

  

ASSOCIATED DIESEASES: blood pressure ,diabetes millitus type 2 

  

PERSONAL HISTORY : 

diet: apatite issues

Sleep: no proper sleep 

Bowl and bladder : normal 

FAMILY HISTORY 

hypertension and BP since 30years

Hypothyroidism since 15 years  

  

DRUG HISTORY : 

insulin 1

C

CLINICAL FEATURES 

Pallor:pale

Icterus: no 

Cyanosis:no 

Clubbing: no 

Lymphacenopathy:no 

Edema:no 

VITALS: 

Temperature:98.6

Pulse: 78  beats for minute 

Respiratory rate:16 cycles for minute 

Blood pressure: 160/80mm of hg 

Sp02 :98% 

Q/A

1.Is it necessary to increase insulin doses with increase in range of hyperglycemia? 

2.which type of diet can be taken ?

PROVITIONAL DIAGNOSIS:

HYPERGLYCEMIA AND HYPERTENSION