Prefinal long case

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.  

 This is a case of 25yr old male came from narketpally,car driver by occupation 

Cheif complaints: generalised weakness since 3months

Hopi:

3months ago he developed increased frequency of urination (also nocturia) also he has  generalised weakness after  10days of developing weakness he went to the local hospital where he  was diagnosed with diabetes , doctor prescribed medication then he took rest for 10days (where his weakness got subsided even though he has increased frequency of urination

15days back his frequency of urination was subsided

After completion of 10days he went to his work (he drives 4-5hrs in a day) he again developed generalised weakness even though he didn't stop driving due to financial crisis

He had 2-3 episodes of head ache throbbing type of pain relived by medication associated with neck pain

He changed his diet plan after diagnosis . he takes roti (2 times in a day), afternoon he eats fruits .his appetite decreased due to nausea 

Tingling sensation since 3months over the sole 

 H/o Weight loss 2-3kgsince3months

Yellowish discoloration of urine since 2 days

Blurring of vision since 2days

Past history:not a known case of htn, epilepsy,TB, thyroid abnormalities,no surgeries

Personal history:diet -mixed

Appetite -normal

Bowel and bladder movements are regular

Sleep -adequate

Occasionally he drinks alochol (in family function)

Family history:his 50yrs old father has diabetes since 5yrs

General examination:- 

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

Moderately built, moderately nourished

His mid arm circumference -12cm

Abdominal circumference -35cm






Pallor:- absent 



Icterus:- absent 



Cyanosis:- absent 

Clubbing:- absent

Generalized lymphadenopathy:- absent

Bilateral pedal edema :- absent 

Per abdomen:

On Inspection

Shape of abdomen :-flat 

Umbilicus is inverted.

No scars , engorged veins.

All parts of abdomen are moving equally with respiration 

On palpation:- all inspectory findings are confirmed.

 abdomen is soft, non tender 

On bimanual examination of kidney- kidney are not palpable.

On percussion:- no shifting dullness and no fluid thrills.

On auscultation:- normal bowel sounds are heard

Respiratory examination:

Shape of chest-elliptical

Trachea-central 

Bilateral air entry present 

Vesicular breath sounds are heard 

No added sounds 

Cvs: 

Apical impulse present

S1,s2 are heard 

CNS: higher mental functions intact   

                  Rt.    Lt        

   Bulk: Normal Normal

Tone:

Upperlimb. Normal. Normal

Lowerlimb. Normal Normal 

Reflexes: biceps. +. +   

                 Triceps. +. +

                 Supinator. +. +

                 Knee. +. +

                 Ankle. + +

             

Sensory examination 

Spinothalamic tract   

 Crude touch 

                    Rt.            Lt

Upper limb -Normal Normal

Lower limb- normal normal

Pain

Upper limb Normal Normal

Lower limb normal 

Temperature 

Upper limb Normal Normal

Lower limb normal normal 

Posterior column

Fine touch.   Rt.        Lt

Upper limb Normal Normal 

Lower limb normal normal 

Vibrations. Normal 

Cortical 

Tactile localisation

                     Rt.           Lt

Upper limb Normal Normal 

Lower limb normal normal 

Joint sense:normal 

Two point discrimination:normal

Stereognosis

Upper limb Normal Normal 

meningeal signs absent

Provisional diagnosis:type 1 diabetes mellitus  with hypertryglyceridemia



On 12/6/23







13/6/23





14/6/23


On 13-6-23
Fbs-183mg/dl
Plbs-277mg/dl
On14-6-23
Fbs-214mg/dl
Plbs-208mg/dl



 









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