50 year women with uncontrolled diabetes

This is online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs. 


This e-log book also reflects my patient centred online learning and your valuable inputs on comment box is welcome.


I’ve 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.

A 50 yr old female,anganwadi worker by occupation,resident of nalgonda came with chief complaints of fever ,chills,headache since 2 weeks.

History of presenting illness:

Patient was apparently asymptomatic 7 years back.

Then she was diagnosed with diabetes due to complaints of fever, headache and generalized body pains since 7 years.

She had a history of usage of inhaler since 6 years.

Since 2 weeks she developed fever,chills,headcaheheadcahe and generalized body pains for which she went to local hospital and found to have increased blood sugars , fever and she was treated for that and did not get subsided.

She was getting fever intermittently and was relieved with medications.

History of past illness:
Diabetes since 7 years.
No history of hypertension,TB, CAD.

Personal history:
Normal appetite
Regular bowel 
Normal micturition
No addictions
No allergies
Family history:
Not significant

General examination:
She was conscious, coherent, cooperative and well nourished.
No pallor,clubbing, cyanosis, lymphadenopathy,pedal oedema 
Vitals:
Temperature:100.2F
Pulse:84/min
Respiratory rate:18/ min
Blood pressure:100/70mm Hg
GRBS:560 mg %
Systemic examination:
Cardiovascular system:
S1,S2 are heard and no cardiac murmurs.
Respiratory system:
Vesicular breath sounds are heard
No dyspnoea
Central nervous system:
No functional deficits.
Abdomen:
No tenderness,no palpable mass
Provisional diagnosis:
Uncontrolled diabetes 
?Dengue
Investigations:



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