General Medicine e-log Diabetes mellitus type 2 with hypertension

 Case study:-

A 47 years old female patient with complaints of Type 2  Diabetes mellitus with hypertension

July 04,2021.

I am P Sai kiran and this is a case that I have come across in the discussion group, described below:-
A 47 year old female patient came to casualty with chief complaints of REASON FOR ADMISSION

. Weakness since morning
.Vomiting
.Headache since afternoon progressive in nature
.Fever today morning for which he was taken to a local hospital and got treated symptomatically. From there he was referred to one hospital for further treatment. Pt was brought to casuality

No other complaints.
• Patient History: k/C/O Hypertension Since 1year on medication but stopped 1month back.

Medication:Atenolol

Social History :NS

• Family History :NS

Allergies :NKA
PHYSICAL EXAMINATION

. Patient is moderately built and nourished

. General: PICCKLE(-ve)

P: pallor, 1: icterus, C: cyanosis, C: clubbing, K:

koilonychia, L: lymphadenopathy and E: edema
( -ve)


CVS :S1 and S2 heard

 RS: NVBS
NVBS - normal vascular bialteral system

CNS: Conscious and well oriented

P/A: Soft and non-tender

 SOAP ANALYSIS


SUBJECTIVE EVIDENCE

• Weakness

.Vomiting

• headache

• Viral fever


OBJECTIVE EVIDENCE:-


*BP 170/110mmHg

*PR :100b/min

*FBS 183mg/dl

*RBS 181mg/d

*PPBS :198mg/dl

ESR 35mm/hr

ASSESSMENT:-

. Based on the subjective and objective evidence the case is assessed to be as:


TYPE-II DIABETES MELLITUS WITH HYPERTENSION

GOALS OF TREATMENT


Patient specific:

*To reduce Vomiting

*To reduce headache

Disease specific:

*To bring RBS,PPBS & FBS to normal level To bring B.P to normal Level

*To bring temperature to the normal Level

 PROGRESS CHART

TESTS:-

D1

BP:-  170/110mmH 9
Pulse:-   88b/min

D2

BP:-  130/90mmHg
Pulse:-80b/min

D3

BP:-  140/90mmHg
Pulse:-  80b/min

THERAPEUTIC PARAMETERS

• To bring RBS,PPBS & FBS to normal level.

To bring B.P to normal Level

• To bring temperature to the normal Level

TOXICITY PARAMETERS

•Inj Cefbact: Excessive gas in stomach, Dizziness, Diarrhea

•Tab Telma Changes in vision, Dizziness, increased heart rate

•Inj Rablet : Skin rash, headache, dizziness

•Inj Periset: Chest pain, headache, abdominal pain 

• Tab Dolo:Nausea, rashes, liver damage

Tab Allercet DC Skin rash, headache, high BP

Tab Geminor-M: Headache, Nausea, hypoglycemia

MEDDISCHARGEICATION:-



DRUGS:-.                                                DOSE:

Tab PECEF (cefpodoxime).                200mg

Tab TELMA.                                           40 mg

Cap CYRA.                                             20+20+10mg
D(rabeprazol e+domperiod ene).      


Tab ALLERCET DC.                                 10+10mg

TaGEMINOR-M.                                         1+500mg

Diet and life style modifications:-

• Salt restricted diet(<2.4gm/day) ,low fat diet,

weight reduction if over weight

Physical activity like brisk walking • Start mild exercises 5-10 min a day

• Avoid exercising if the FBS is >300 mg/dl or < 70 mg/dl • Eat small meals frequently

• Do not take more glucose containing food

and eat fibre rich food.


Thank you:-

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