GENERAL MEDICINE - A 20 YEAR OLD MALE

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment .

A 20 yr old male who is resident of nalgonda came to OPD on 18th of january. 

CHIEF COMPLAINT :-

A 20 yr old male came to opd with chief complaint of :

-Loss of weight since 1 month 

-Excessive drinking of water since 6 months. 

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic 1 month back. Then he noticed gradual loss of weight nearly 7 kgs (73 kgs to 67 kgs) in a span of 1 month.

He had h/o polydypsia since 6 months(drinks 7 to 8 liters of water per day).He had H/0 polyuria.

He had h/o tingling sensation of fingers of lower limbs.He had no h/o fever,fatigue,giddiness and burning micturition.

HISTORY OF PAST ILLNESS :-

He had history of covid 2 years back and had a h/o acute fulminant hepatic failure. 

He had h/o post covid Multisystem inflammatory syndrome. 

He had h/o denovo type I DM 2 years back. 

No h/oHtn, thyroid, TB, epilepsy, asthma. 

PERSONAL HISTORY :-

Diet - Mixed

Appetite - normal

Bowel and bladder movements - regular

Sleep - Adequate

Addictions - Regular alcohol

Allergies - None

FAMILY HISTORY :-

No relevant family history. 

PHYSICAL EXAMINATION :-

General Examination:-

Patient is conscious , coherent , cooperative and well oriented to time , place and person. 

He is moderately built and well nourished. 

No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy. 

Vitals:-

Temperature : Afebrile

BP : 130/80 mm HG 

Pulse rate : 76 bpm

Respiratory rate : 16 cycles/min

Grbs:160 mg/dl  

CLINICAL IMAGES :-

SYSTEMIC EXAMINATION :-

CVS - S1 S2 heard,no murmurs present.

Respiratory system - Bilateral Air entry is normal. 

Normal vesicular breath sounds heard. 

Abdomen - soft , non tender 

CNS - no focal neurological deficits. 

INVESTIGATIONS :-

                 18/01/23               19/01/23

Plbs :-     403mg/dl                403mg/dl

Fbs :-       222mg/dl                118mg/dl

Serum 

creatinine:- 0.8mg/dl              0.8mg/dl

HbA1c :- 7.5%                          7.5%

Albumin :- 4.5                          Nil

RFT :-

Serum uric acid - 2.7

Serum electrolytes -

           Sodium - 140

           Potassium - 50

           Chloride - 98

LFT :-

Sgot - 13

Sgpt - 12

ALP - 234

TP - 7.0

Complete Urine Examination :-

Color - pale yellow

Appearance - clear

Reaction - acidic

Specific gravity - 1.010

Bile pigments - Nil

 

 ECG :-

  PLBS :-

FBS :-

Serum Creatinine :-

Gycated Hemoglobin :-

APTT :-

Liver function test :-

Complete urine examination :-

Ultrasound :-

Chest X ray :-

DIAGNOSIS :-

     Uncontrolled Type 1 diabetes mellitus

TREATMENT :-

Inj HAI SC/TID

Inj NPH SC/BD