General medicine-5

Hi,This is faizal. M 3rd Semester student. This is an online elog book to discuss our patient health data after taking his consent. this also reflect my patient Centered online learning portfolio

Chief complaint: A 50 years old male patient labourer by occupation came to OPD with chief complaint of weakness ,Dizziness

History of present illness:patient  was apparently asymptomatic since 1year then started  complaint  for weakness, dizziness  and high sugar level.He was kept on OHA's used for  2month and he stopped medication  for 2 months and he developed  complaint  of severe  weakness, polydypsia,polyuria so he visited  a private hospital  at nalgonda found to having high sugar(uncontrolled diabeties).he was started with Insulin since then but patient is taking  Irregularly

Past history:history of diabetes since 1year


Drug history:t.THIAMINE
                         t. GLIMI-M1
Family history: no family history of present illness

Personal history : patient is taking mixed type of diet
Normal appetite
Frequency of urination is increased
Normal bowel movement
He is chronic alcoholic since 13years
Normal sleep cycle
No history of hypertension, no history of asthma  , no history of TB, no history any thyroid disorders

General examination: patient is conscious, coherent and cooperative

Bp-120/92mm hg
RR-13/min
No pallor
No icterus 
No lymphadenopathy
No oedema
No clubbing of finger
No Cyanosis

Systemic examination -s1,s2heard
Normal vasicular breathing


Investigation:
Ultrasound shows -fatty infiltration of liver and hepatomegaly






Diagnosis: UNCONTROLLED DIABETES WITH FATTY LIVER


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