39M Diabetes and Hypertension

E-LOGS MEDICINE

Hi, I am Arefin Sadat, a final-year MBBS student. This is an E-Log that depicts the patient-centred approach to learning medicine. This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post. I hope you learn valuable information after giving it a good read.

 CASE OF A 39-YEAR-OLD MALE 

 This is a case of a 39-year-old male who is a school teacher in profession. 

 CHIEF COMPLAINTS 

1) Diabetes for 11 years 
2) Hypertension for 7 years 

History of Presenting Illness 

 The patient was reasonably well and healthy till he was in class 7. After that, he developed fever along with shivering, which later diagnosed as Malaria. He used to lead a very unhealthy lifestyle such as not doing any exercise at all, eating a lot of fatty food, sugary things and also accustomed to betel leaf. 

 In 2011, he started feeling thrist all day long and his weight gradually decreased from 90 to 82 kg. On test, his blood sugar found 380 mg/dl. On suggestion from locals, he started taking curry leave juice, which reduces his sugar level to 150 mg/dl. In the mean time, he also started physical exercise daily. 

 In 2016, he was diagnosed with hypertension and started taking mild antihypertensive drugs. 

 By 2019, his blood sugar decreased, HbA1C 5.5 mmol/mol. So he decreased the dose of the medications by his own. In 2021, his blood sugar again elevated,HbA1C 10 mmol/mol, random blood sugar 220/230 mg/dl. He then again started taking the high doses of the medication but no visible improvement noticed.

 In 2019, his serum uric acid and serum creatine appeared in borderline. 

 History of Past Illness: Malaria, when the patient was in class 7. 

 Family History: His father is a patient of heart block and his mother is a patient of hypertension and stroke. 

 Patient's Diet -

-Breakfast: nut, salad, millet 
-Lunch: seasonal fruits, millet 
-Evening: Tea, puffed rice,cucumber 
-Dinner: Rice, vegetable, fish(occasionally) 

 Personal History : 
 Weight - 72 kg 
Bowel- Normal 
Bladder movements - Normal 
 Addiction - Betel nut. 

Clinical image:
 




 Clinical report:

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