MARCH 4,2023
GM CASE 4
Case scenario....
Hi,This is P.Bhavana of 3rd BDS student.This is an online eblog book to discuss our patient's health data after taking her consent.This also reflects my patient centred online learning portfolio.
CASE SHEET:
A 55 Years old female with chest pain.
CHEIF COMPLAINT:
Chest pain since 3 days back.
Shortness of breath since 3 days back.
History of present illness:
She was apparently asymptomatic 15 years back and then she noticed a swelling over right foot and dizziness, then she went to the hospital there she is diagnosed with diabetes mellitus.From then she started taking medications ( oral hypoglycemia drugs).suddenly she stopped taking medications one month ago.Insteadly she started taking multivitamin tablets which she considered it as oral hypoglycemia drugs.
Then since 10 days she started having pain near lumbar region,which aggrevated and radiated to chest 3 days back.she was febrile since 3 days.she was having shortness of breath grade 3 type since 3 days back.
History of past illness: No significant past history
Personal history:
She usually wakes up early in the morning at 5:00 clock .she used to have tea and have rice in the break fast and she used to go for labour work and return in the evening and used to have her dinner and sleeps at 8:30 pm.
After diagnosed with diabetes she decreased her diet and her sleeping timings are changed. She had no sleep last night also.Her micturation was increased.This is the difference I found out from her routine day life.
Family history:
No significant family history.
General examination:
Pallor: no
Icterus: no
Cyanosis: no
Clubbing: no
Lymphadnopathy: no
VITALS
Pulse:101 per minute
Temperature:98°.8f
Bp: 120/60 mmHg
Spo2: 96%
Addictions:
Tabacoo chewing since 6 years stopped before 3 days.
Provisional diagnosis: Uncontrolled diabetes mellitus.
Questions from patient:
What health problems does it cause ?
How can I manage diabetes?
Questions from my side:
How chest pain is related to diabetes?
What is the reason for shortness of breath?
