Case: 55 year old woman with hypoglycemia

Neha Pradeep, MBBS 9th semester



Roll no: 99



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 centered online learning portfolio 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.

Case:
A 55 year old lady, a daily wage worker, was shifted to the AMC due to hypoglycemia induced loss of consciousness before her ophthalmic surgery. 

History of Presenting Illness:
Patient was apparently asymptomatic 1 year ago, when she developed a gradual, progressive loss of vision in her left eye. 
Not associated with any black spots, excessive watering, photophobia, or pain. 
When admitted to the Ophthalmology department before the surgery, she lost consciousness suddenly. 

History of Past Illness:
Patient was brought to the hospital 2 years ago, with loss of consciousness. She was diagnosed with Diabetes Mellitus type 2. 
She is not a known case of Hypertension, Tuberculosis or CAD. 

Personal History:
Diet: Mixed 
Appetite: Normal
Sleep: Adequate 
Bowel and Bladder: Normal
No addictions, no allergies. 

General Examination: 
Patient is conscious, coherent, and cooperative.

Temperature: Afebrile
Pulse Rate: 83 beats/min
Blood Pressure: 110/70 mmHg 
Respiratory Rate: 18 cycles per minute 

Pallor: None 
Icterus: None 
Clubbing: None 
Cyanosis: None 
Lymphadenopathy: None 
Edema: None 








Fever chart: 


ECG: 



Blood Sugar Charting: 




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