GENERAL MEDICINE


 GM case 1

February 20,2023

February 20,2023
Case scenario....

Hi, I am MP Sanjana, 3rd year bds student. This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patients centered online learning portfolio

CASE HISTORY: a 60 year old man with diabetes and hypertension 


CHIEF COMPLAINT:sugar , body pains - hands and legs,  headache


HISTORY OF PRESENT ILLNESS: patient apparently asymptomatic  2months ago
Bodypains from 2months
Progressing type of pain . Body pains are relieved by medication 
No seizures or fever 
Headache rare but throbbing type 

PAST ILLNESS :
diabetes - since 5 months 
Hypertension- since 6months,  150/90 mm hg 
No asthma , tb, CAD

PERSONAL HISTORY: 
Diet : mixed
Appetite: loss of appetite 
Sleep:no proper sleep
Bowel movements: irregular
Micturation: normal
Addiction: smoking, alcohol

FAMILY HISTORY:no history of similar complaints in the family

GENERAL EXAMINATION:
pallor: no
Icterus:no
Cyanosis:no
Clubbing :no
Edema: no

DRUG HISTORY:
METFORMIN 500MG
AMLODIPINE 5MG

Q/A
1.what type of diet should be followed by diabetic patients?
2.what foods to be avoided to control blood pressure ?
3. Is diabetes hereditary disease?

PROVISIONAL DIAGNOSIS: 
DIABETES AND HYPERTENSION 


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