A 46 year old male with Type 2 Diabetes mellitus

Hi, I am K. Komali , 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio 

                            CASE SHEET

CHIEF COMPLIANTS

A 46 year old male patient who is a shopkeeper by occupation and resident of West Bengal cane to OPD with the following symptoms:-
Chest pain from 12 years
Generalized abdominal pain in right and left flank regions and lower abdomen from 12 years
Pain in fingers from 12 years
Acidity from 10 years

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 12 years ago, after which he started experiencing abdominal pain, chest pain and pain in the interphalangeal joints of fingers. Pain was gradual after onset and increased progressively over years.
The pain was intermittent ( an episode of pain every 1 hour ) and pricking in character which relieved on taking medication; not associated with fever, nausea/vomiting.
Epigastric pain for past 10 years for which he takes pantoprazole 40mg every day.
Polyuria and polysypsia since an year, but no medication or any regulated diet

HISTORY OF PAST ILLNESS

Suffered pneumonia when he was a child.
Type 2 Diabetes mellitus from one year.
No Hypertension
No Asthma
No Tuberculosis
No Cardiovascular disease
No Epilepsy

FAMILY HISTORY

Father had Type 2 Diabetes mellitus

PERSONAL HISTORY

Appetite : Decreased
Diet : Mixed
Bowel movement : Regular
Micturition : Normal
Sleep : Adequate
Addictions : 
       Alcohol from 5 years
       Chronic smoker
Allergies:
        Chicken and eggs cause dermatitis

Vitals:
BP : 100/80 mm of Hg
Pulse rate : 70bpm

PHYSICAL EXAMINATION
General Examination:
Conscious, coherent and coperative
Well built and well nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema

INVESTIGATIONS: 

Fasting Blood Sugar
Post Lunch Blood Sugar
Liver Function Tests
Serum Creatinine
DIAGNOSIS:
Type 2 Diabetes mellitus


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