73 YEARS MALE WITH DIABETES SINCE 3YEARS
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-centred online learning portfolio and your valuable comments on comment box is welcome.
I've 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 a diagnosis and treatment plan.
73 YEARS OLD MALE CAME TO OPTHAL OPD WITH C/O DOV IN LEFT EYE SINCE 3 YEAR
PATIENT SHIFTED TO GM OPD IN VEIW OF HIGH BLOOD SUGARS(Rbs :516mg/dl)
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK THEN HE DEVELOPED DOV IN LEFT EYE
PAST HISTROY:
k/c/o DM since 3 years
Not a known case of HTN CAD, CVA, ASTHMA, TB, EPILEPSY, THYROID DISEASE, CKD
Personal History :
Diet : Mixed
Appetite : Normal
Sleep : Adequate
Bowel movements : regular
Addictions : occasional alcohol 2times/month stopped 2years back
Family History : no significant family history
On Examination :
Patient is conscious coherent cooperative
General Examination :
No pallor icterus, cyanosis, clubbing, lymphadenopathy and edema.
Vitals :
At the time of admission :
Temp. : 98.4
PR : 72 bpm
RR :16cpm
BP : 120/80 mm Hg
SpO2 : 98% @ RA
Systemic examination :
CVS : S1 S2 +, No murmurs
RS : BAE +
P/A : Soft, non-tender
CNS :
GCS : E4V5M6
MENTAL STATUS: AAOx3(awake,alert and oriented) , memory intact, fund of knowledge appropriate
LANG/SPEECH: Naming and repetition intact, fluent, follows 3-step commands
CRANIAL NERVES:
II: Pupils equal and reactive, no RAPD( relative afferent pupillary defect), left eye VF(visual field) deficits left eye normal
III, IV, VI: EOM(extraocular movements) intact, no gaze deviation, no nystagmus.
V: normal sensation in ophthalmic (V1), maxillary (V2), and mandibular (V3) segments bilaterally
VII: no asymmetry, no nasolabial fold flattening
VIII: hearing to speech decreased in both ears (rinne test positive ,webers test negative)
IX, X: normal palatal elevation, no uvular deviation
XI: 4/5 head turn and 4/5 shoulder shrug bilaterally
XII: midline tongue protrusion
Motor: Muscle bulk and tone are normal. Strength is full bilaterally.
| Biceps | Triceps | Wrist ext | Finger abd | Hip flex | Hip ext | Knee flex | Knee ext | Ankle flex | Ankle ext | ||
| R | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | |
| L | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 | 5 |
| Biceps | Triceps | Knee | Ankle | Hoffman | Plantar | |||
| R | 2 | 2 | 2 | 1 | negative | down | ||
| L | 2 | 2 | 2 | 1 | negative | down |
SENSORY:
Normal to touch, pinprick, vibration, temp all limbs
No hemineglect, no extinction to double sided stimulation (visual & tactile)
Romberg absent
Coordination: Normal finger to nose and heel to shin, no tremor, no dysmetria
STATION: normal stance, no truncal ataxia
GAIT: Normal; patient able to tip-toe, heel-walk
Provisional diagnosis: DM II SINCE 3YEARS
LEFT EYE IMMATURE SENILE CATARACT
Treatment:
1.INJ HAI S/C TID BEFORE MEAL
Comments
Post a Comment