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A 50 year old female patient e log

E-LOG GENERAL MEDICINE
Hi, This is K.Srinija , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

★ CASE SCENARIO 

A 50 year old female  patient who is House wife came to the OPD with chief complaints of :
- Nausea and vomitings since 2 days
- weight loss since since  1 year 
- Heavy menstrual bleeding since 1 nd half year

★ HISTORY OF PRESENT ILLNESS :

- Patient was apparently asymptomatic 2 days ago and developed vomitings which are billious in nature , food as content if taken food which is preceded by severe nausea since 2 days , 20-30 episodes till the time of admission
No HISTORY of fever, loose stools, pain abdomen,
- patient did not take insulin on the night before admission and on morning of admission day , she is on OHA 's and shifted to insulin 15 days back when she visited local hospital with weakness , giddiness and GRBS is 400 mg/dl
- h/o weight loss since 1 year nearly 15 - 16 kgs i e. 48-50 kg to 32 kg
- h/o heavy menstrual bleeding since 1 nd half year associated with clots but not associated with pain , used medication but not subsided 
 
★PAST HISTORY:- 
-DM type 2 since 13 years
Before 13 years due to loss of consciousness, she went to a hospital where regular investigations are done to find her DM type 2.
For which she is under regular oral medication since then GLIMIPERIDE M2 
-15 days back they were changed to INSULIN( 10U-X-8U) with GLIMI afternoon 
-Right Ear discharge since 12 years insidious in onset intermittent, mucoid type, non-foul smelling and non-blood stained and relieves temporarily on medication not associated with pain, loss of hearing. 
-NO history of HTN, TB, Asthma, leprosy, CAD, CKD. 

Surgical history:-
Tubectomy was done before 25 years

★PERSONAL HISTORY:-
Diet:- veg ( egg)
Appetite - increased 
Sleep:- Adequate
Bowel and bladder:- Regular
Addictions:- NIL

★FAMILY HISTORY:-
No significant family history 


★MENSTRUAL HISTORY:-
LMP:- 13/7/22 
Age of menarche:-13 yrs

PAST CYCLES:-
4/30 regular cycles
Not associated with pain and clots 2 pada per day.

PRESENT CYCLES:- Since 18 months 
Heavy menstrual bleeding 
Associated with clots but not associated with pain. 4 pads per day.

Obstetric history:-
G3 L2 D1


★ALLERGIC HISTORY:-
No known allergies to drugs or any kind of food. 

★GENERAL EXAMINATION:-
-She is conscious coherent and cooperative and well oriented towards time, place, and person 
Weakly built and weakly nourished. 
- pallor - present
- No - icterus, cyanosis lymphadenopathy, clubbing, oedema of foot

WEIGHT:- 32 kgs

VITALS:-

Temperature - 98.6F
PR:- 96 bpm
R.R:-18 CPM
B.P:- 110/80 mm Hg
SPO2:- 95%
GRBS :- 406 mg / dl

★SYSTEMIC EXAMINATION:-

CARDIO VASCULAR SYSTEM:-
 - S1; S2 heard; no murmurs

RESPIRATORY SYSTEM:-
- Bilateral air entry presents normal vesicular breath sounds are heard all over the chest


PER ABDOMEN:-
- soft, non-tender.

CENTRAL NERVOUS SYSTEM:-
-no focal deformities,
-No signs of meningeal irritation
-Cranial nerves - Normal
-Motor system - Normal
-Sensory system - Normal

★ INVESTIGATIONS
5/8/22
7/8/22
8/8/2022
9/8/22
10/8/22


★DIAGNOSIS:-

DIABETIC KETOACIDOSIS SECONDARY TO INADEQUATE INSULIN, ADENOMYOSIS, ANEMIA UNDER EVALUATION WITH A HISTORY OF WEIGHT LOSS, TYPE 2 DM SINCE 13 YRS

★Rx

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