55F Diabetes Metabolic 11 years HTN 23 years WB PaJR

 

May 19, 2023

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

A 55 yr old woman a homemaker and resident of West Bengal belonging to upper middle class according to BG Prasad classification presented to the OPD with chief complaints of fatigue since 2 yrs.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 11 yrs ago, when she had episodes of insomnia and fatigue, for which she visisted the hospital and was incidentally diagnosed with type 2 diabetes mellitus. She was advised lifestyle modification i.e: diet and exercise. In 2014 she presented with similar complaints and advised medication. Patient has been regularly taking medication since 9 yrs.

H/O polyphagia

N/H/O polydypsia, Polyuria, Nocturia

N/H/O SOB

HISTORY OF PAST ILLNESS

K/C/O HTN since 23 yrs, uses medication regularly

NN/K/C/O TB, Asthma, Epilepsy

TREATMENT HISTORY

Diabetes; metformin and Glimeperide

Hypertension: Amlodipine

FAMILY HISTORY

Mother is K/C/O HTN since 56 yrs.

MENSTRUAL HISTORY

Menarch: 13 yrs

Regular periods: 4/30, not associated with pain or clots

PERSONAL HISTORY

Diet: Mixed

Appetite: Normal

Exercise: Walking 1-2 km everyday

Addictions: Tobacco containing paan 5-6 paan everyday since 2005

No known allergies

GENERAL EXAMINATION

Patient was C/C/C and oriented to space and time.

[07-06-2025 11:55] PPM 1: Ki oshudh khacchen?

Koto dose?

Oshudher chobi dose dekha jai moton share korun

[07-06-2025 13.02] PA: Sokalay khabar Agay 1 ta koray khachay

[07-06-2025 13.04] PA: Sokle  500 mg, Ratay 500 mg 2 bar

[07-06-2025 13:05] PA: Ai guli ke khabay Aktuk Janaben Kindly

[07-06-2025 16:47] PPM 1: Hain aeguno dose barate habe

Kalke aeki dose a khali pete, breakfast er du ghonta baade, lunch er du ghonta baade ebong dinner er du ghonta baade koto sugar hocche sheta janale koto dose barate habe sheta janano jeto

[10-07-2025 00:12] PA: 1. Before Breakfast - 201(F)

2. After Breakfast - 321(pp)

3. Lunch after 2 hours - 342(pp)

4. After Dinner 2 hrs - 391(pp)

[10-07-2025 00.13] PA: Sokalay khabar Agay 1 ta koray khachay

[10-07-2025 00.14] PA: Sokle  500 mg, Ratay 500 mg 2 bar

[10-07-2025 00:15] PA: Ai Obosthay  ke korbay Kindly Janaben

[10-07-2025 06:55] PPM 1: Increase tablet Glimepiride to 1.5 mg from it's current 1mg in the morning and add 0.5 mg at night and then repeat the four blood sugars again after three days

[10-07-2025 08:21] PA: Ok Doctor Babu

[14-07-2025 00:03] +91 98511 32289: ডাক্তার বাবু   আজকে  Fisting  এবং  2 ঘণ্টা বাদ দিনে  3 বার ব্লাড টেস্ট  করে  পাঠালাম

[14-07-2025 00:17] PA: 13,07,25

1)  241 (F) ----- 9 am

2)  209 (pp)---- 11,45 am

3)  298 (pp) ---  04,20 pm

4)। 335 (pp) ---  11,55 pm

Tablet Glimepiride 1.5 morning, 0.5 at night

After Breakfast Metformin 500 mg and after dinner - 500 mg

[14-07-2025 00:19] PA: Dakther Babu ke korbo Akhon, Janaben kindly

[14-07-2025 07:09] PPM 1: Make metformin 500 mg 3 times after breakfast, lunch and dinner

Increase glimiperide to 2 mg before breakfast and 1 mg before dinner

Please share her daily food plates before and after eating and hourly activities 

Also her 10 readings of BP taken over an entire day at random hourly intervals

[14-07-2025 10:20] PA: Ok Dakther Babu

[29-07-2025 10.56] PA: Breakfast

Lunch at 15.03