60 M WITH TYPE 2 DIABETES MELLITUS AND HYPERTENSION

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Ihave been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 60 year old man, resident of suryapet, labourer by occupation, came to the ophthalmology op with complaints of diminution of vision in the right eye and was referred to the general medicine department because of uncontrolled diabetes. 

History of present illness- 

patient was apparently asymptomatic 3 years ago. then he developed diabetes mellitus and hypertension.

Past history - 

history of cardiovascular accident 9 months ago, for which he was admitted in the hospital.

patient is a known case of diabetes mellitus since 3 years and is on medication ever since. 

patient is also a known case of hypertension since 3 years and is on medication since then. 

no history of tuberculosis, bronchial asthma, hyper or hypothyroidism. 

Personal history -

sleep - adequate 

bowel and bladder - regular 

appetite - normal 

diet - mixed (non vegetarian) 

addictions- used to smoke cigarettes and drink alcohol (90 ml/day)  until 9 months ago. 

Family history - 

not significant 

Daily routine- 

he wakes up at 5:30 am and walks for a while. then he freshens up, drinks tea and passes time. 

he eats breakfast (idli or dosa) at around 8 am and rice for lunch at 12 - 1 pm. he then spends time with his grandchildren and plays with them, drinks tea in the evening followed by eating rice for dinner at 8 pm. 

He used to work as a labourer but stopped going to work since 9 months because of the weakness in his left arm and left leg following the cerebrovascular accident.  

General examination-

Patient is conscious coherent and cooperative, moderately built and moderately nourished 

pallor - absent 

icterus - absent 

cyanosis - absent 

clubbing - absent 

generalised lymphadenopathy - absent 

pedal edema - absent 

Vitals-

temperature - afebrile 

Pulse rate - 80 bpm 

Blood pressure - 130/90 mm of hg 

respiratory rate- 18 cpm 

Cardiovascular system- 

no thrills, 

no cardiac murmurs, 

S1 and S2 sounds heard

Respiratory system- 

dyspnoea is absent, 

position of trachea is central,

no wheeze, 

vesicular breath sounds present  

Abdomen- 

normal in shape, 

no tenderness, 

no palpable mass, 

hernial orifices are normal,

no bruits or free fluid,

liver and spleen are not palpable, 

bowel sounds are present

Central nervous system - 

conscious 

speech is normal 

gait - hemiplegic gait 

no neck stiffness, no kernings sign

                                            right                 left  

Tone

upper limb                      normal.           increased

lower limb.                     normal.           increased 

Power.                             

upper limb                        5/5                      4/5

lower limb                        5/5                      4/5

Reflexes

biceps                               -                           +1

triceps                               -                           +1

supinator                          -                            -

knee                                 -                            +2

ankle                                -                             -

Provisional diagnosis - 

Diabetes Mellitus type 2 

Hypertension 

k/ c/ o CVA 9 months ago

Investigations-

Treatment - 

tab metformin 500 mg - bd

tab glimiperide 1 mg - bd 

tab telma 40 mg - od 

tab ecospirin 75 mg - od 

tab rosuvastatin 10 mg - od