36year male with complaint of fatigue since 8months.

A 36 yrs old male  came to OPD with chief complaints of fatigue since 8 months 

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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.came to the hospital with

CHEIF COMPLAINTS of fatigue since 8months.

HOPI
A 36 yrs old male  ,who is a teacher by occupation ,came to OPD with chief complaints of fatigue since 8 months .
Patient was apparently asymptomatic 8months ago  ,then he had burning sensation in his both eyes , Generalised weakness every evening , polydypsia,polyuria  for which he went for medical check where his blood sugar levels were 370 gm/dl then he was adviced some medications in local hospital. After 1month of medication patient developed nausea and fullness of stomach   which was  relieved without any medication. 
 From 6months  patient  is having decreased appetite and
since 3months he is  complaining of pain in the calf muscles  more on 
standing  and sitting  with legs in hanging postion 
 And relieved on folding legs
No complaints of tingling or numbness and headache
He had history of generalised body pains on doing vigorous work... For which he was adviced to take protein powder in a local hospital after which his muscle pains were relieved.
No history of fever, cough, cold ,
night sweats, loose stools, chest pain, palpitations.
Now No polydypsia, polyphagia,polyuria 
-Patient had complaints of pain  while retracting perpuce over glans and during sexual intercourse since one and half year. 
PAST HISTORY 
diabetic since 8months is on medication 
N/k/c/o hypertension,asthama, epilepsy, TB CAD.
no significant surgical history

PERSONAL HISTORY
Diet-mixed
Appetite - decreased
Bowel movements-Regular
Bladder movements-burning micturation on and off since 8 months
Addictions
 Consumes alcohol occasionally (once ina month), 
Is a smoker since 10yrs , smokes 2-3 cigarette s per day  - pack years 1-1.5
Chews guttkha..1-3 packets since 17 yrs
GENERAL EXAMINATION 

Height-164cm
Weight -55 kgs present weight. 
8months back  his weight was 68kgs..
BMI:20.4

No pallor,icterus, cynosis, clubbing, pedal edema, lymphadenopathy
Mid arm circumference:
Mamc=23-0.2
22.08
Abdominal circumference @level or umbilicus =75
Circumference@level of ASIS_79.5
Abdominal circumference/Mamc - 3.28
Waist to hip ratio _1.06

Vitals
Bp-120/80mmhg
Pulse rate: 80bpm 
RR:18cpm
Fastingblood sugars:111gm/dl  

SYSTEMIC EXAMINATION
 
CVS: S1,S2 +  
no thrills & murmurs heared

RS: BAE+
No added breath sounds heared

CNS: no focal abnormalities detected

P/A: soft ,non tender, bowel sounds heared.
 

Treatment:
7 point profile was  performed
15/10/22
1:30 pm -160 mg/dl
16/10/22
9:00am- 111mg/dl
1:00pm-71 mg/dl
2:45pm -165mg/dl
5:30pm -178mg/dl
8:00pm-150mg/dl
10:10pm -155mg/dl
2:00am-101mg/dl
8:00am-125mg/dl
FBS on 17/10/22 : 119/dl
 Investigations:
16/10/22
18/10/22
Treatment:
8am before breakfast 
Tab Glimerperide 1mg before food and Tab Metformin 500mg after food 

1pm before lunch  Tab Metformin 500mg after food.

8pm before dinner_ Tab Glimerperide 0.5mg before food - Tab Metformin 500mg after food 

Surgery referal was taken in view of, pain while retracting perpuce over the glans.
 On genital examination: 
Penis- normal in size
 Narrow-Perputeal orifice, perpuce appears edematous and retractable with little effort.
Glans-normal (smegma covering the glans)
Pain while retracting the perpuce 
B/L testis,epidydimis,scrotum -normal
 Advice- lignocaine gel for local application
Gential hygiene (glans)as explained to patient. 
Circumcision if no symptomatic improvement.









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