General medicine elog 2

 General medicine elog 2

Hi , I am Anamika Maiti ,3rd semester 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.

A 52 YEAR OLD FEMALE PATIENT CAME WITH COMPLAINTS OF HYPERGLYCEMIA AND SHOULDER PAIN 

A 52 female patient , housewife resident of nalgonda came with complaints of 

Uncontrolled sugar with Type -2 DM 

Known case of tinea corporis

Known case of HTN

B/L parotid enlargement 

Generalised weakness 

B/L shoulder pain 

HISTORY OF PRESENT ILLNESS :

Patient is complaining of uncontrolled sugar with Type -2 DM since 2 months .Patient is diabetic since 8 years.Experiencing high sugar levels since 2 months (usually around 280 - 350 ). Patient was on oral medication but shifted to insulin ( 3 times a day ) since 15 days when she had high sugar levels .  

She is Hypertensive since 2 years (bp higher than 140 m mHg ).

Complaining about shoulder pain since 2 months when lifting the shoulder. 

Complain of swelling in the feet.Increases when sitting for long hours and relieved on taking rest.

PAST HISTORY:

DM type 2 since 8 years

HTN for 2 years

Not a case of asthma, tb , CAD, surgeries

Was tested covid +ve 2 times ( vaccinated )

PERSONAL HISTORY :

Married and housewife

Diet : mixed

Appetite: normal 

Addictions : no

Sleep : normal

Bowels : regular 

Micturition : normal 

Allergies : no

FAMILY HISTORY : none

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative.
No pallor

No ictreus

No cyanosis

No clubbing

No lymphadenopathy

Vitals:

fever : afibrile

 pulse: 100 bpm
 respiratory rate : 22 per minute 
 bp :  110/80 mmhg

SYSTEMIC EXAMINATION: