GM - 04

March 04 2023
Case 4

Hi , I am V.Shivani 3rd year dental student . This is online elog book to discuss our patient health data after taking her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET :
A 73 year old women came with a chief complaint of shortness of breathe and chest pain .

CHIEF COMPLAINTS :
Fever with overall body weakness 15 days back
Shortness of breathe and chest pain ,shivering from 2 days

HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 15 years ago and gradually developed weakness and went to checkup and diagnosed with Diabetes .
She was fine till 15 days back and developed fever with weakness and diagnosed with kidney disease. After few days came again with shortness of breathe.

PAST ILLNESS :
Hypertension and diabetes from 15 years .
Insulin was prescribed for diabetes , it is self administered by her.

PERSONAL HISTORY :
Diet : mixed diet
Appetite : loss of appetite 
Sleep : normal
Bowel and bladder : normal
Addictions : nil

FAMILY HISTORY: Nil

GENERAL EXAMINATION :
Built : normal
Nourishment : normal
Consciousness : in conscious
Pallor : present
Cyanosis : no
Lymphadenopathy : no
Clubbing : no
Icterus : no
Oedema : pedal Edema

VITALS :
Temperature : 98.8 F
Pulse :110
SpO2 :94
Blood pressure :170/100

PROVISIONAL DIAGNOSIS :
DIABETIC NEPHROPATHY

Q/A
1. Are there any other possible diagnosis ?
2. Insulin is self administered ,does any insulin dosage changes lead to this condition?
3. Does the chest pain indicate diabetes have effected the heart ?

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