53 F WB k/c/o DM since 5 years


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-centred online learning portfolio and your valuable comments on comment box is welcome.


I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.







 CASE :- 

C/C


PATIENT CAME WITH THE CHIEF COMPLAINTS OF

  •  Tingling sensation of B/L UL and LL since 2 years

  • Burning sensation of abdomen since 2 years 




H.O.P.I


Pt was apparently asymptomatic 4 years ago. Then she started developing occasional lack of sleepiness during night. During same period of time she was diagnosed to have Diabetes .

Pt. Started developing shortness of breath on climbing stairs since 2 years


Tingling sensation of fingers ( aggravated on exposure to soaps or detergent) since 2 years.

Tingling of foot since 2 years

Pt. Also gives a history of finding her feet swollen ( Right >Left) after waking since 2 years.

Burning sensation of abdomen since 2 years.

Burning sensation of hands since 1 year.



Pt. Also gives a history occasional pain in upper lateral part of thigh and lateral part back.





Past history

Pt. Is a known case of DM since 5 years(on Tab. Glipy Met 500 sr, thyroid disorder since 4 years.( thyroxine sodium) Hypertension since 4 years.( Telmilsartan 40mg)

Pt. Is irregular with medications.



Pt. Is N/K/C/O TB, ASTHMA, CAD, CVA, EPILEPSY ETC.


Family history:-

Pt. Has similar history in family.
Both of her sisters are having similar complaints and are a k/c/o of DM


PERSONAL HISTORY:-

DIET :- MIXED

APPETITE:- NORMAL

BOWEL AND BLADDER:- REGULAR

SLEEP :- USUALLY ADEQUATE

No addictions












DVL REFFERAL WAS DONE I/V/O ITCHING OVER THE BODY.





Opthalmologist's opinion was taken i/v/o D.o.v and retinopathy  changes..




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