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case of a 65 year old female patient

Hello this is likhita,
This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered online learning portfolio and your valuable inputs on the comment box is 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 in reading and comprehending clinical data including history, clinical findings,investigations and come up with diagnosis and treatment plan. 

A 65 year old female resident of aliya mandalam tadipalam came to the hospital with 
chief complaints of 

- blurring of vision since 2 years
- polyuria and polydipsia since 2 years
- constipation from 3 months

HISTORY OF PRESENTING ILLNESS

Apparently the patient was asymptomatic till 3 years ago when she first was diagnosed with diabetes in a hospital for which she was given metformin tablets now switched to insulin injection
-Then after an ear she developed polyuria 3-4 times a night and polydipsia but no polyphagia
-Along with polyuria there seemed to be burning sensation while micturition around the same time for 5-10 seconds but it was bearable which progressively became uncomfortable. 
-She also had tingling and burning sensation in both of her feet 
She seemed to have problem in passing stools and goes once for 2-3 days. She had no associated pain in the abdomen. 

PAST HISTORY

She is a known case of DM and took metformin tablets who's medication wasn't sufficient to manage her conditions on an irregular basis.
N/k/c/o CAD ASTHMA EPILEPSY TB HTN
She had tubectomy done 20 years ago

PERSONAL HISTORY

Appetite : reduced
Weight loss: seen
Diet: she seems to eat pickle and rice more rather than having any vegetables and diets due to financial conditions. 
Addiction : none

VITALS

Temp:98.5°F 
Bp: 120/80 mmhg 
PR: 84 bpm
RR: 20 cpm

GENERAL EXAMINATION

No pallor
No icterus 

No cyanosis

No clubbing

No generalised lymphadenopathy
No pedal edema 


Systemic examination

Cvs : 

Precordium normal 
No thrills ,
On auscultation 
S1,S2 heard ,no murmurs 

CNS: 

Higher mental functions :intact
Cranial nerves :intact
Motor system:Normal power,tone,Gait
Reflexes:normal
Sensory examination:Normal
No meningeal signs
Tremors : absent

Respiratory system: 
Shape of chest:Bilaterally symmetrical, Elliptical in shape
No visible chest deformities
No kyphoscoliosis,
Abdomino thoracic respiration, No irregular respiration

Trachea is central 
Auscultation: 
Normal vesicular breath sounds heard 

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