Hi, I am p.samhitha, 5th Sem Medical Student.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

October 16, 2023

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

5 5 5 5 5 5 5 5 5 5

REFLEX

Biceps

Triceps Knee Ankle Hoffman

Plantar

R 2

2 2 1 negative

down

L 2

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

2.7 point grbs monitoring

93-Samhitha