57 YEAR OLD WAS PRESENTED RO OPD WITH YELLOW ISH DISCOLORATION OF SKIN,CONJUNTIVA, ABDOMINAL PAIN.
July 28, 2023
This is an online e log book to discuss our patient 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.
This is a case of 57 year old female , housewife staying in Mathavanga , West Bengal.
CHIEF COMPLAINTS:
- pain in abdomen( since 3 1/2 months {mild} , 2months {progressed} )
- tingling pain in the abdomen , sudden in onset. (increased on eating )
- can't stand / sit without support (since 1month)
- iching all over the body (since 1month)
- generalized weakness
- yellowish discoloration of sclera and skin and stools ( since 25 days ).
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2months back then she noticed yellowish discoloration of eyes and urine and went to hospital and on further evaluation she was diagnosed to have type 2 diabetes mellitus and was started tab.dapgliflozin 10mg in the morning and tab.sitagaliptin 50mg + t.metformin 500mg at night.
C/o pain over the periumbilical region since 2months ,pricking type of pain ,non radiating,no aggrevating and relieving factors.(slight Decrease in pain from last 2days
H/o occasional tingling and numbness of upper limb and lower limb.
No c/o polyphagia,polydypsia,nocturia.
Past history -
In 1996 diagnosed to have tumour of the uterus ( hysterectomy done)
In 2010, she had difficulty in breathing during winter season and monsoons (? Bronchial Asthma ) and used tab.deriphylline 450mg 1/2 tab PO/BD for 5-7days during the attacks along with inhaler ,presently she is not having any difficulty and not using.
K/c/o diabetes mellitus 2months and on tab.dapgliflozin 10mg in the morning and tab.sitagaliptin 50mg + t.metformin 500mg at night.
Dietary history -
She consumes
tea along chapathi in the morning
Sometimes chole (boiled and mashed )
Afternoon - rice and dal along with some vegetables.
In between biscuits as snacks
And chapathi at night.
Normal - appetite
Adequate -sleep
Regular bowl movements
Normal bladder movements
No history of alcohol, smoking and chewing of tobacco .
FAMILY HISTORY:
No significant family history.
General examination:
Patient is conscious, coherent and cooperative.
No lymphadenopathy, clubbing, koilonychia, clubbing.
Pallor present.
Icterus: present
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