Case of a 46 year male with Type 2 Diabetes Mellitus

This is an E log book to discuss our patients de-identified health data shared after guardians informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.

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


 

A 46 years old male patient came to the hospital with the chief complaints of :


CHIEF COMPLAINTS

The patient presented to the hospital with the chief complaints of

  • Chest pain from 12 years.
  • Generalised abdominal pain predominantly in the right and left flank regions and the lower abdomen from 12 years.

  • Pain in the fingers from 12 years.
  • Acidity from 10 years.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 12 years ago, 12 years ago he started experiencing chest pain, abdominal pain predominantly in the right and left flanks and the lower abdomen, and pain in the interphalangeal joints of the fingers. The pain was gradual in onset and increased progressively over the years. The pain was pricking in character and intermittent in nature with one episode of pain every hour. The pain was relieved by taking medication. The pain was not associated with fever, nausea or vomiting.

The patient has been experiencing epigastric pain for the past 10 years, for which he takes pantoprazole 40mg every day. Pain is relieved by taking the medication.

One year ago the patient started experiencing polyuria and polydipsia. On visiting the hospital he was diagnosed with type 2 diabetes mellitus. The patient is not taking any medication and does not have a regulated diet. One year ago the patient also started experiencing blurred vision which causes him headaches on reading.


HISTORY OF PAST ILLNESS 

The patient had a bout of pneumonia when he was a child, which caused him chest pain. He recovered after receiving treatment and the chest pain stopped.

He is a known case of Type 2 Diabetes mellitus from 1 year.

He is not a known case of hypertension, asthma, TB, Thyroid condition, CVD, or Epilepsy.

No history of blood transfusions.


FAMILY HISTORY

His father is a known case of Type 2 Diabetes mellitus.


PERSONAL HISTORY

DIET- Mixed diet

APPETITE- Decreased

SLEEP- Adequate

BOWEL AND BLADDER MOVEMENTS - Normal

ADDICTIONS-

ALCOHOL- From 5 years, consumes 1 glass a day.
SMOKING- Chronic smoker- 2-5 cigarettes /day

ALLERGIES- chicken and eggs cause dermatitis.


EXAMINATION


VITALS

BP- 100/80mmHg

PR- 70bpm

AFBRILE


GENERAL EXAMINATION


The patient is conscious, coherent and cooperative.

He is well built and well nourished.

Pallor- Absent

Icterus- Absent

Cyanosis- Absent

Clubbing-  Absent

Lymphadenopathy- Absent

Koilonychia- Absent

Pedal oedema- Absent


SYSTEMIC EXAMINATION

PER ABDOMEN:-
INSPECTION- Shape of the abdomen- obese
The umbilicus is central and inverted 
No visible engorged veins, scars or sinuses
No visible pulsations
All quadrants are moving appropriately with respiration
No visible peristalsis
PALPATION-
Soft, mild tenderness at epigastric region 
Small mass in the epigastrium about 1 cm in size
No hepatomegaly 
No splenomegaly
PERCUSSION-
Liver dullness not obliterated
AUSCULTATION - 
bowel sounds heard 

CNS
The patient is conscious and coherent.
Speech is normal.

CVS:- 
 S1, S2 heard 
No thrills
No murmurs

 
RESPIRATORY SYSTEM :- 
 BAE+ 
 NVBS heard 








INVESTIGATIONS


POST LUNCH BLOOD SUGAR          


     

BLOOD UREA   


                                          

COMPLETE URINE EXAMINATION   



HEMOGRAM



LIVER FUNCTION TEST



SERUM CREATININE



SERUM ELECTROLYTES



ECG 

                                     


FASTING BLOOD SUGAR



USG

                                     


GLYCATED HEMOGLOBIN



6 MIN WALK TEST



XRAY

PA VIEW CHEST XRAY



PA VIEW ABDOMEN



PROVISIONAL DIAGNOSIS

Diabetes mellitus type 2
Non ulcer dyspepsia 

MANAGEMENT

1. TAB. Glimepiride 1mg PO/OD

2. TAB. Metformin 500mg PO/OD

3. GRBS Monitoring


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