GENERAL MEDICINE

GM- CASE 2

Tuesday, 7 march 2023

7 march
2023
CASE scenario....

Hi, I am k. Sai madhuri 3rd year bds student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

CASE HISTORY : A 51 year old known case of fever.
CHIEF COMPLAINTS : fever and , foot injure from 20 days

HISTORY OF PRESENT ILLNESS : 
Patient was apparently asymptomatic 20 days back,then he had injury while doing his work .It was not healing,then followed by fever since 15 days,it is intermittent associated  with pain relieve on medication. 

PAST ILLNESS :
7 years back he diagnosed with diabetes on his regular check up  and 5 year back he diagnosed with hypertension on regular check up and  he was on regular medication 
He is taking insulin subcutaneously before every meal 

PERSONAL HISTORY : 
Mixed diet,apatite normal, have proper sleep, regular bowel and micturition. 

FAMILY HISTORY : 
Diabetes : present 
His father  had diabetes 

GENERAL EXAMNLINATION : 
Built : moderately
Nourishment : poor 
Consciousness: in Conscious
Pallor : no
Icterus : no
Cyanosis : no cyanosis 
Clubbing : no clubbing 
Lymphadinopathy : no lymphadenopathy 
Edema : no edema 

VITALS : 
Temperature : 98.6°c/f
Pulse : 100_ beats per minute
Respiratory rate : 16_cycles per minute
Blood pressure : 170/100 mm of Hg
SPO2 : 94%

PROVISIONAL DIAGNOSIS : 
            Uncontrolled Diabetes type 2
                Diabetic foot with hypertension 

Q/A

1. Is surgery only way or is there any other way  


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