20 year old male with uncontrolled sugars

 This is an 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 patient's 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 the comment box.


This is a case of 20 year old male came with cheif complaint of weight loss of nearly 7 kgs (73kgs to 67 kgs ) within 1 month,polydypsia since 6 months 

History of present illness:- 
Patient was apparently asymptomatic 1 month back then he noticed gradual loss of weight nearly 7 kgs ( unintensional - from 73 kgs to 67 kgs) in a span of 1 month.He had h/o polydypsia since 6 months(drinks 7 to 8 liters of water per day).H/0 polyuria,delayed wound healing present .Tingling sensation of fingers of lower limbs.No h/o numbness or loss of sensation.No h/o fatigue,giddiness.No h/o fever,burning micturition.

Past history:-
K/c/o type 1 DM since 2 years( on inj.HAI 40U inj.NPH 40 U ).H/o fulminant hepatic failure a year back and h/o CVA 1 yr back .Not a known case of Htn,thyroid,TB,epilepsy,asthma,CAD.

Personal history:-
Mixed diet
Sleep and apettite normal
Bowel and bladder regular
No addictions
No known allergies

Family history:-
Not significant 

GENERAL EXAMINATION:

-  Patient was examined after taking his consent 
-  Patient is conscious , coherent , cooperative , well oriented to time , place and person 
-  He is moderately built and nourished 
-  No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy 

His vitals: 

Temperature : afebrile
BP : 120/80 mm HG 
Pulse rate : 78 / min 
Resp.rate : 16 cpm
Grbs:160 mg/dl 

Systemic Examination:

CVS- S1 S2 heard,no murmurs present.

RS - bilateral Air entry present
Normal vesicular breath sounds heard

Per Abdomen : soft , non tender 

CNS :no focal neurologocal deficits 

Investigations
Plbs: 403 mg/dl
Fbs:- 222mg/dl
Sr.creatinine: 0.8 mg/dl
HbA1c: 7.5 %

Diagnosis:
Uncontrolled type 1 Diabetes mellitus

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