55 yrs old male with HTN, DM

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: Pt is a 55 yrs old male, who works as a govt employee.

At the age of 26 yrs, one day while sitting at home, he experienced lightheadedness. After it happened 2-3 times subsequently, he went to a Dr. HTN was detected and medications started. His BP came under control. 

In 2000, he stopped medication for 15-20 days, again he c/o lightheadedness, neck stiffness, and his tongue was rolling backward (tongue spasm). After this happened 2-3 times, he was hospitalized for 1 day.

In 2006, his relatives told him he is losing wt and he was also feeling a bit lethargic. While on routine checkup, Dr. diagnosed DM (PP 288 mg/dL). Medication started. 

7 yrs ago, while on a routine checkup, his BP was found to be 140/90 mmHg. It was not coming down even on changing medications. Then Dr. increased dosage to b.d from o.d, after which his BP came within 130-120/80-82.

Pt had lost 10 kg body wt in past 10 yrs.

ADDICTION: Pt started smoking at age of 25 yrs. Smoking on an average of 10 cigarettes/day. Sometimes, 2-3 more sometimes 2-3 less.

CHIEF COMPLAINTS AND PT REQ.: HTN since past 28 yrs. 

DM since past 17 yrs.

FAMILY HISTORY: Father - CVD, died after a brain stroke

Mother - DM detected at a later stage of life

Sister - HTN

CURRENT MEDICATION: 

Janumet 50mg/500mg (Sitagliptin and Metformin) b.d

Eurepa 1 (Repaglinide) o.d 

Olmesar 40 b.d

Vinicor AM 50/5 (amlodipine + metoprolol) b.d

Gibtulio Met 12.5mg/500mg (Empagliflozine + Metformin) o.d

Rosufit CV 20 (Rosuvastatin + clopidogrel) o.d





REPORTS: 







PROVISIONAL DIAGNOSIS: HTN, DM




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