56 yr old male with type 2 DM & history of Carcinoma bladder

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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis "to develop my competency and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.

CHIEF COMPLAINTS 

A 55 years old male, shopkeeper by occupation presented to the hospital with complaints of

Lower back pain for 5 years 

Chest pain for 2 years

History Of Presenting Illness 

The patient was apparently asymptomatic 23 years ago, when he experienced polydipsia, polyuria and polyphagia and visited a doctor. On further investigations, the patient had 400 mg/dl fasting blood sugar and was diagnosed with Type 2 Diabetes Mellitus. The patient was started on antidiabetic medication. 

The patient currently has occassional episodes of tingling sensation and blurred vision.

10 years ago, the patient had one episode of hematuria. The patient visited a hospital. On evaluation, the patient was diagnosed with High-Grade Urothelial Bladder Carcinoma, without any muscular involvement. 

The patient underwent surgery for the same and was advised a follow-up every 2 years since. 

7 years ago, the patient was diagnosed with Hypertension and was given Olmesartan Medoxomil 40 mg 

5 years ago, the patient slipped and fell on his right side, on a cement road,  from a terrace 8 feet above the ground.

The patient was disoriented for 2-3 minutes after falling. Since the fall the patient experienced lower back pain which was dull in character, experienced on and off, and radiating to the front. The pain is aggravated on sitting continuously in one position and relieved on changing position or stretching. 

Since 2 years, the patient is experiencing Chest pain localised to the right and left side of the sternum, which is dull in character, lasting 5- 10 minutes. The patient experiences  2-4 such episodes per month. The pain aggravates on exertion and is not associated with Nausea or Vomiting. 

PAST HISTORY 

The patient is not a known case of TB, CVD or Epilepsy.

No history of allergies.

TREATMENT  HISTORY

Treatment for Bladder Carcinoma - 

 The growth was 1.3 cm, pedunculated, in the posterior wall of the urinary bladder. 

- Surgical treatment: Total excision of growth with underlying detrusor excision 

- Medical management : BCG instillation after surgery 

The patient is currently taking 

Metformin Hydrochloride and Glimepiride Tablets

Vildagliptin and metformin hydrochloride tablets (50 mg + 500 mg)

Olmesartan Medoxomil tablets 40 mg from the past 7 years - once every two days

PERSONAL HISTORY 

Appetite: Normal

Diet: mixed diet 

Sleep: adequate 

Bowel and bladder movements normal 

No history of allergy 

Addictions: The patient is a chronic smoker, consumes 2-4 cigarettes a day 

No history of alcohol consumption 

FAMILY HISTORY 

The patient's grandfather had a history of Diabetes Mellitus type 2 

No Family history of cancer 

GENERAL EXAMINATION 

The patient is conscious, coherent, and oriented to time place and person. 

The patient is well built and well nourished 

Pallor - Absent 

Icterus - absent 

Cyanosis - Absent 

Clubbing - Absent 

Koilonychia - Absent 

Lymphadenopathy - absent 

Oedema - Absent 

VITALS 

Temperature - afebrile

Blood Pressure - 110/70 mmhg 

Pulse rate - 87 beats per minute 

CVS

S1, S2 Heard 

No thrills and Murmurs 

Respiratory

BAE + 

NVBS heard

CNS 

The patient is conscious coherent and oriented to time place and person 

No Focal Neurological Deficits 

 

INVESTIGATIONS 

1. Ultrasound Report

2. ECG

3. X-RAY Abdomen  AP View

BIOCHEMICAL INVESTIGATIONS 

    

Pathological Investigations 

Provisional Diagnosis 

- Type 2 Diabetes Mellitus with a history of carcinoma of the urinary bladder 

Treatment

Tablet Gemer 2mg PO/BD

Tablet Vylda-M 50/500 PO