77 yr old female

 This is an online e log book to discuss our patient health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim to solve the patient’s clinical problem with collective current best evident based input.


This E blog also reflects my patient cantered online learning portfolio and your valuable inputs on the comment box is welcome.I have 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.


Case: A 77 year old female presented to  Ophthalmology opd with complaints  of  diminishion of vision in right eye.


History of present illness: 

Patient was apparently asymptomatic 1 year back when she had nocturia due to which she went to the hospital and was diagnosed with diabetes for which she was medication. She takes Glimeperide 1mg and Metformin 500mg twice  daily  ( morning and evening)ever since. 


Patient has itchy skin lesion over left foot since one year. She also complains of itching over genitals since one year. 


She developed diminished vision 6 months back which is insidious in onset, gradual in progression. and associated with itching. Not associated with redness. 


Past history : 


Known case of hypertension since 1 year and takes tab losartan daily .


Not a known case of TB, asthma, epilepsy



Personal history : 



Mixed diet


Appetite is reduced 


Normal bowel and bladder movements 


Sleep is adequate 


No Addictions 



Daily routine : 



Before 


She used to wake up at 5:00 am. She walks 1/2 a kilometer to buy milk. Then at 8:00 am after having breakfast, she goes and sits at a shop beside the house and returns home at 2:00 pm for lunch and then goes to sleep. After waking up, she has dinner and sleeps at 10:00 pm. 



Now 


She used to wake up at 5:00 am. She walks 1/2 a kilometer to buy milk. Then at 8:00 am after having breakfast, takes medication. She goes and sits at the shop and returns home at 2:00 pm for lunch and then goes to sleep. After waking up, she will have dinner and sleep at 10:00 pm. 


There is no change in the routine of the patient except for medication for diabetes and hypertension being taken regularly. 



Family history: 


Not significant 



General examination 


Patient was conscious ,coherent and well oriented to time and place.

Patient was moderately built and nourished 



Vitals


BP 140/90 mm of Hg


Pulse 80beats /min


Temperature afebrile


Respiratory rate  16 cycles/min



No pallor, icterus, cyanosis, clubbing, lymphadenopathy 



Eye: 



Right eye 

Diminised vision 


Ocular movements are not limited 


 


Visual acuity         Counting fingers, 2m       6/60


Lids                       normal                             normal


Conjunctiva           Muddy                             Muddy


Cornea                  nasal pterygium              nasal pterygium


Anterior chamber  PACD = 1/2 CT               PACD = 1/2 CT


Iris                        


Pupil                   normal size, reactive     normal size, reactive


Lens                   IMSC grade I - II                



Skin Examination: 



single well defined


Silvery white plaque noted over the left foot 



Systemic examination:



CVS- S1 S2 heard no murmurs


CNS- No focal neurological deficit


RS- Normal vesicular sounds heard


P/A- 


scaphoid abdomen 


non tender, no palpable mass


bowel sounds heard 







Treatment given:


Human acrapid (10u- 10u -10u) + 

NPH ( 8U MRNG AND 8U NIGHT).



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