47 Yr old Female with Hypoglycemia

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

K.Medha Reddy, intern 

Roll No: 61

I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE: 

C/O shivering since morning

C/O sweating since morning

HOPI: Patient was apparently assymptomatic 4 months back, then she had sweating, brief loss of consciousness and went to local hospital and was diagnosed to have a hypoglycemic attack.

Patient C/O shivering, sweating, brief loss of consciousness with drooling of saliva yesterday afternoon and went to local hospital.

She had similar 2 episodes in the midnight yesterday. She was bought to our hospital for further management.

Past History:

H/O similar complaints in the past 4 months back. 

K/C/O DM since 5 yrs is on T. GLIMI-M1

Not a K/C/O HTN,TB, Epilepsy, Asthma, Thyroid disorders 

Personal history:

Appetite: normal

Diet: mixed

Bowel habits: decreased since 3 days 

Bladder habits: Decreased since 1 day

Addictions: nil

Family history:

No significant family history

On general examination: 

Pt is c/c/c

No pallor, icterus, cyanosis, clubbing, and lymphadenopathy. 

Pedal Edema + 

Vitals: 

Temp: afebrile

PR: 112bpm

RR: 24 cpm

BP: 180/110mmHg

Spo2: 100%

GRBS: 38 mg/dl

Systemic examination:

CVS: 

S1 S2 heard, 

no murmurs

RS: 

B/L Air Entry +

Normal Vesicular Breath Sounds

P/A: 

Shape: obese

Soft, non tender

Bowel sounds+

CNS: 

Conscious

Speech: normal

No focal neurologic deficit