60yrs old Female Came to OPD with Shortness of breath, palpitations

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.















This E blog also reflects my patient centered 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.


60 yr old female came to OPD with chief complaints of
1.Shortness of breath since 1 yr
2.palpitations since 1 yr

HOPI:
Patient was apparently asymptomatic 2years back and then she developed fever associated with weakness ,for that she went to a local doctor and later diagnosed with DM.


later she developed weakness , shortness of breath on exertion( Grade 2) not associated with cough or wheeze  , palpitations since 1yr 
DAILY ROUTINE: 
Before DM : 
She usually wakes up at 6:00 am and Eats Breakfast (Rice and curry  rarely Tiffin like IDLI ,DOSA ) at 7:30 am 
Goes to work by 8:00 am 
Used to have lunch by 1:00PM(Rice and curry )  
Comes back home at 5:00AM , Eats Dinner at 8:00 PM 
Sleeps by 9:00 PM 
AFTER DM : 
Wake up at 7:00 AM , Breakfast by 8:00 am mostly Roti and curry , Doing Household works and having lunch at 1:00pm ( Rice and Curry ) Post lunch Rest for 2hrs , Watching Television and Dinner at 8:00PM (Roti and curry).



PAST HISTORY: 
Known case of DM 
Not a known case of HTN, TB , ASTHAMA, EPILEPSY, THYROID DISORDERS 

PERSONAL HISTORY :
Married 
Diet : Mixed 
Apettite : Normal 
Bladder Movements : Normal 
Bowel Movement : Irregular 
Sleep : Adequate
No Addictions
No known Allergies 


 FAMILY HISTORY: 
No significant family History 


TREATMENT HISTORY: 
Metformin 500MG 
Glimiperide 1 MG  for DM 


GENERAL EXAMINATION: 
Patient is conscious, non cooperative, coherent 

Moderately built and nourished



No Pallor ,icterus ,Cyanosis ,Clubbing and Lymphadenopathy , Edema 





Vitals:-

Temp- afebrile

PR-110

BP-117/70 mm Hg 

RR- 18cycles /min 



SYSTEMIC EXAMINATION:

CVS-S1 S2 heard , No murmurs 

RESPIRATORY - Non  vesicular breath sounds , Bilateral Air entry present 

CNS- No focal neurological Deficit 

PER ABDOMEN -soft and non tender


Clinical Pictures : 


INVESTIGATIONS : 

RANDOM BLOOD SUGAR : 
LIVER FUNCTION TEST :

RENAL FUNCTION TEST: 

HAEMOGRAM: 

URINE EXAMINATION: 


ECG : 

2D ECHO : 

PROVISIONAL  DIAGNOSIS :
Generalised  weakness due to Hyperglycemia 
Palpitations under evaluation 







 



 


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