ГОСУДАРСТВЕННОЕ БЮДЖЕТНОЕ ОБРАЗОВАТЕЛЬНОЕ УЧРЕЖДЕНИЕ

ВЫСШЕГО ПРОФЕССИОНАЛЬНОГО ОБРАЗОВАНИЯ

«БАШКИРСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ УНИВЕРСИТЕТ»
МИНИСТЕРСТВА ЗДРАВООХРАНЕНИЯ РОССИЙСКОЙ ФЕДЕРАЦИИ

Кафедра Эндокринологии
Заведующий кафедрой: д.м.н., профессор
Моругова Татьяна Вячеславовна
Преподаватель: к.м.н., доцент Авзалетдинова
Диана Шамилевна

История болезни
Пациент: Davidova Larisa Ivanovna , 60 years.
HbA1c level 9 %
Complication : chronic kidney disease

Клинический диагноз:
Сахарный диабет 2 типа

Куратор: студент 6 курса

Л-604b группы лечебного факультета БГМУ
специальности "Лечебное дело" очной формы обучения
Дата: 06.03.2024
Aina Rossario Alan, Nizamudeen, Nikitha

Уфа 2023
PASSPORT PART

1.Full name: maticov makcim evgenevich

2.DOB: 10.01.2000. 24 years

3.Gender: male

4.Date of admission: 29.02.2024. 09:48

5.Profession: technologist

6.Height: 184cm

7.Weight: 75kg

Complains: abdominal pain, nausea and vomiting, frequent urination upon admission.

ANAMNESIS MORBI

He has been ill with diabetes mellitus type 1 10 years before in 2014. He is taking basal insulin therapy
tresiba and kviksin. since the himself.after 2 years of diagnosis of type1 diabetes he presented to clinic
with epigastric pain and vomiting at 2016. He also clarified that before 2 years of diagnosis of diabetes
he developed angina and he was treated for angina.he is smoking and he left drinking alcohol before 1
year. And he has no family history of diabetes mellitus. Now he is presented with nausea and vomiting
and abdominal pain with polyuria.he drinks 15 glasses of water per day complaining of thirst.other signs
and symptoms of diabetes was absent.he is taking insulin therapy regularly on time without skipping.

He has no history of infections disease. also he says he lose his weight in past 1and half yr around 10 kg.
He adds that he has gradual vision loss in 1 year his spectacles number has increased 1D. There is history
of past trauma.he has no history of allergy.

ANAMNESIS VITAE

Born : ufa , republic of bashkortostan

Resident: ufa

He is not married and no child.

Allergic reaction is denies drugs.

Nutrition includes foods with a limited amount of carbohydrate.

STATUS PRESENS OBJECTIVUS

General condition of moderate severity.

Position active. Consciousness is clear. The reaction to others is restrained.

Height – 184cm, weight – 75kg.the constitutional type is normosthenic.

The skin is pale in color, there are no areas of hyper- and depigmentation, rashes, scars, or ulcers. The
skin is dry, turgor is reduced.

Visible mucous membranes are pale pink, moderately moist, without pathological changes. The oral
cavity is sanitized, there is acetone smelling breath. The tongue is pink, not coated, moist, the papillae
are well defined. The condition of the gums and tonsils is good.Skin is slightly dehydrated.

Subcutaneous fat tissue is normal.Inspection is easy.There is no swelling.

Peripheral lymph nodes are not palpated:

The muscular system is well developed, muscle strength and tone are preserved, there is no pain.

Respiratory system

Nasal breathing is free. The chest is of regular shape, symmetrical, longitudinal dimensions prevail over
transverse ones, supraclavicular and subclavian fossae are pronounced, the sternoclavicular angle is
smoothed. The ribs have a slight oblique direction, the intercostal spaces are smoothed, the epigastric
angle is approximately 90 degrees. The shoulder blades are adjacent to the chest and are at the same
level.

The respiratory movements of the right and left halves of the chest are the same, the excursion is in full.
Breathing is abdominal, shallow, rhythmic, respiratory rate per minute = 16.

On palpation, the chest is painless, elasticity is reduced. Voice tremors are reduced and occur equally in
symmetrical areas of the chest.
With comparative percussion over the entire surface of the lungs, no dullness of the pulmonary sound is
determined.

During auscultation of the lungs, vesicular breathing is heard over the entire surface of the lungs. No
additional breath sounds are heard. Bronchophony is weakened and occurs equally in symmetrical areas
of the chest.

Circulatory system

When examined, the area of the heart is without pathological changes. The apical impulse is noted in
the 5th intercostal space 1.5 cm medially from the midclavicular line, limited. There are no visible
pulsations in the neck, and the venous pulse is negative. There is no expansion of venous collaterals in
the neck, chest and abdominal walls.

The apical impulse is palpated in the 5th intercostal space 1.5 cm medially from the midclavicular line,
limited, high, strong, of medium resistance. Heart rate 64 beats per minute.

The pulse on the left and right radial arteries is symmetrical, regular, rhythmic, good filling, moderate
tension, large, of normal shape. Pulse rate – 64 beats per minute.

Blood pressure – 130/80 mm Hg.

Limits of relative cardiac dullness.

Right - right edge of the sternum;

Left - 1 cm medially from the left midclavicular line in the 5th intercostal space.

Upper - the upper edge of the third rib on the left.

When auscultating the heart, the sounds are muffled and rhythmic. There are no pathological noises.

Digestive system

The tongue is pink, not coated, moist, the papillae are well defined. The condition of the gums and
tonsils is good.

The belly is cylindrical, symmetrical. The navel is unchanged. There are no hernial protrusions. Peristalsis
of the stomach and intestines is not observed. The skin is pale pink, there is no expansion of superficial
veins. On superficial palpation the abdomen is soft and painless. The divergence of the abdominal
muscles and their tension are not determined.

With deep palpation, the sigmoid colon is located in the left iliac region, palpated in the form of a
painless cylinder with a diameter of 2 cm, of moderate density, does not rumble, and moves 1 - 1.5 cm
in each direction.
On palpation, the cecum is located in the right iliac region. It is palpated in the form of a smooth tube
with a diameter of 3 cm, expanding downwards, painless, purrs, mobile up to 2 cm.

When palpating the ascending and descending sections of the colon, the descending section of the colon
is palpated, has the appearance of a cylinder, smooth, painless.

On palpation, the transverse colon has the shape of a cylinder with a smooth surface, is painless, does
not peristalt, and is inactive.

Liver : Inspection is difficult due to severe flatulence and pronounced subcutaneous fat layer.liver is
enlarged slightly, the edge is dense, painless on palpation.

Size TLD62mm , TPD 125mm.

Echigenicity : slightly increased

Sound conductivity :moderately redused

Vascular pattern : weakened

Structure moderately diffusely heterogenous

Portal vein : Normal

Examination is difficult due to flatulence and subcutaneous fat.

The gallbladder is appears partially contracted

CBD :- Not dialated

Pancrease not enlarged

Dimensions:- head 28 mm, body 18mm, tail 22mm

Contour : fuzzy,uneven.

Echogenicity : increased

Structure: moderately diffusely heterogenous

Abdominal aorta : not visualized

Spleen : slightly enlarged

Dimensions 128*50mm

Structure : homogenous
The stool is regular and formed.

Genitourinary system

Kidney :

Upon examination,Topography: lying on the back is not changed

Dimensions: RIGHT 115x53 mm, LEFT 103x54 mm

Parenchyma: RIGHT 15 MM, LEFT 14 mm

Parenchyma with a slight increase in the echogenicity of the cortical layer.

The outflow of urine on both sides is not impaired urination - up to 8 - 10 times per bowel movement
(polyuria), daily diuresis - up to 5 liters. Nocturia – 3 times per night.

Bladder : not filled

The condition of the external genitalia is without pathological changes.

Nervous system and mental status

Good mood, shallow sleep. Contact with others.

The gait is normal. The reaction of the pupils to light is lively. Tendon reflexes are preserved and well
expressed. Stable in the Romberg pose. No paresis or paralysis was detected. No seizures are noted.
Pain and tactile sensitivity are preserved.

RATIONALE FOR THE PRELIMINARY DIAGNOSIS

Based on complaints of thirst, dry mouth, increased appetite, polyuria,, general weakness and high
blood glucose.

Based on the medical history: It began with the appearance of thirst, dry mouth, frequent urination (up
to 8–10 times a day), taking medicine from last 5 years insulin injection and metformin , the diagnosis
was established: “Type 2 diabetes mellitus, non -insulin-dependent.” started on insulin tresibo around
5 year ago .

Based on objective examination data: General condition of moderate severity. The skin is pale in color,
there are no areas of hyper- and depigmentation, rashes, scars, or ulcers. The skin is dry, turgor is
reduced. Visible mucous membranes are pale pink, moderately moist, without pathological changes.
There is vesicular breathing in the lungs, no wheezing. Heart sounds are muffled, rhythmic, blood
pressure is 130/80 mm Hg. The abdomen is soft and painless. The liver is slightly enlarged, the edge is
dense, painless on palpation. Urination - up to 8 - 10 times per bowel movement (polyuria), daily
diuresis - up to 5 liters. Nocturia – 3 times per night.
preliminary diagnosis: “Diabetes mellitus type 2,noninsulin-dependent type”

EXAMINATION PLAN

RESULTS OF ADDITIONAL RESEARCH METHODS

1. Clinical blood test 20.02.2024

Red blood cells 5.9* 1012/ l

Hemoglobin 174.5 g/l

Color index 0.9

Reticulocytes 0.4%

Platelets 172* 109/l

Leukocytes 9.7 * 109/l

Basophils 0%

Eosinophils 2%

Band 6%

Segmented 67%

Monocytes 6%

Lymphocytes 19%

ESR 6 mm/ h

Hematocrit 52.5%

2. General urine analysis dated 01/07/2010

Color light yellow

Transparency transparent

Precipitate of uric acid salt Slightly

acidic reaction

Specific gravity 1025

Ph 5.0

Bilirubin neg

NIT neg

LEU 3.3

URO norm

Protein neg

Ketones neg

Single white blood cells Red blood cells none

No cylinders

3. Fecal analysis for worm eggs

No worm eggs detected

4. Scraping for enterobiasis

Enterobiasis was not detected

5. Blood test for sugar over time

28/02/ 2024

Fasting glucose 11.4mmlo/l

11:00 11.0 mmol/l

13:00 9.9 mmol/l

15:00 13.7mmol/l

01/03/2024

Fasting glucose 10.1mmol/l

11:00 9.3mmol/l

13:00 10.8mmol/l

15:00 10.1mmol/l
7. Urinalysis according to Nechiporenko

Leukocytes – nil

Red blood cells – nil

Cylinders – not found

8. Biochemical blood test dated 20.02.2024

Glucose 12.11 mmol/l

Urea 11.3 mmol/l

Creatinine 133 mmol/l

CRP 12.2mmol/l

Bilirubin 16.6 mmol/l

9. HbA1c 9 % high

10. Ultrasound of the abdominal organs, retroperitoneal space and pelvis from 01/08/10

Liver d+2.5 cm; s+3 cm, homogeneous, compacted.

Pancreas, spleen, kidneys, bladder - without visible gross focal changes.

Thyroid glands – D: 6.0*1.2*2.0 = 7.54 cm; S: 6.0*1.2*1.8 = 6.79. Total = 14.33 cm.

Conclusion: echo signs of hepatosis

11. Echocardioscopy dated

Structure Revealed Normal

RV wall (cm) 0.5 55

LV EDV (cm) 4.3 3.5-5.7

LV ESD (cm) 3.2 2.3-3.8

RV EDV (cm) 1.5 Up to 3.0

Valvular apparatus

valve structure function

Mitral Normal
Aortic Normal

Tricuspid Normal

Pulmonary artery Normal

Conclusion: no deviations were detected.

Thus, the full clinical diagnosis is: "Basic: Diabetes mellitus type 2, insulin-independent type, moderate
form, increased level of inflammatory markers and creatinine, glycemic control with a high degree of
risk.

Complications: chronic kidney disease

Background : obesity II degree

BMI =38.8

TREATMENT PLAN

1) Insulin Tresiba (sc)

2) Metformin 500mg 3 times a day

3) Farxiga 10mg at night