62 year old female patient with high blood sugars

This is an online E Logbook to discuss our patient's de-identified health data shared after taking his/her guardian's signed informed consent. Here, we discuss our individual patient's problems through a series of inputs from an available global online community of experts to solve those patients' clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

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A 62 year old female patient was admitted into the medicine ward with chief complaints of  high blood sugars.

HISTORY OF PRESENT ILLNESS:

Patient initially came to ophthalmology OPD with the complaints of decreased vision since 7 months which was insidious in onset and gradually progressive and was subsequently admitted for cataract surgery.
On routine investigations RBS was found to be 515 mg/dl and was referred to general medicine.

PAST HISTORY:

Patient is known case of Diabetes mellitus type 2 since 10 years and is on TAB. METFORMIN and TAB. GLIMIPERIDE 

No other comorbities

Vitals 

Patient is conscious, coherent, cooperative 
Oriented to time/place/person

Temperature : afebrile
BP: 120/90 mm hg
PR: 82 bpm
GRBS: 518 mg/dl

SYSTEMIC EXAMINATION 

CVS: S1S2 HEARD, NO MURMURS
RS: BAE +, CLEAR
P/A: SOFT, NON TENDER
CNS: NAD


INVESTIGATIONS :

RBS: 151 mg/dl
SEROLOGY: negative 

ADVICE: 7-POINT GRBS MONITORING 

TREATMENT:

1. INJ. HAI according to GRBS
2. 7-point GRBS monitoring 




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