GM case - 3

GM Case:3

March 5,2023
Case scenario..

Hi, I am S.Sharvani, 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 65 years old male, resident of Kanagal, came with
Chief complaint: Tingling sensation of the body since 2 months and frequent urination.

HISTORY OF PRESENT ILLNESS: patient is asymptomatic 3 months back but he had low grade fever back then but since 2 months he had tingling sensation of both upper and lower limbs when he took toddy 5 days back and associated with burning sensation of his feet. He also had polyuria associated with burning micturition. He had pedal edema but it relieved on taking rest.

HISTORY OF PAST ILLNESS:
Diabetes: he has a history of high blood sugar(230mg/dL). He known it when he went for the eye camp 2 months ago but he neglected and took no medication.
Hypertension: No
Heart surgery: No
Asthma: No
Tuberculosis: No

PERSONAL HISTORY:
Patient is married
Occupation: Farmer
Diet: Mixed diet
Appetite: Irregular
Bowl and bladder: no constipation but frequent urination
Sleep: Normal
Allergies: No
Addictions: smokes chutta since 20 years(2 per day) and drinks toddy frequently.

FAMILY HISTORY: NIL

General examination:
Patient is conscious, cooperative and coherent
Pallor: No
Icterus: No
Cyanosis: No
Clubbing of fingers or toes: No
Malnutrition: No
Dehydration: No
Lymphadenopathy: No
Edema of feet: Yes - pitting type

Vitals:
BP: 110/70 mm Hg
Respiration: 20 /min
Pulse rate: 92 bpm/min

Diagnosis: Diabetes Mellitus - 355 mg/dL

Medication:
Pregabalin

Questions:
1. Will i recover after taking my medications?
2. Is there will be any effect to my heart?