THE CASE HISTORY
Clinical diagnosis:
Main disease____
__
Complication of the main disease _
Related disease _____________
__
_______________
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Surname, name, patronic_____MANZOOR SHAHID_____________
Age___60________
Sex___MALE______
Family status____MARRIED________________
Education (primary, secondary, tertiary)
Occupation_BUISNESSMAN___Post__OWNER_________________
Place of employment___BIHAR____________________
Permanent address______PATNA , BIHAR, INDIA___
Date of admission to the hospital__18/05/2022_
The patient complains of dizziness and headache for 3 days.
 The patient has a history of Hypertension for 6 months under
medication (Amlodipine 5 mg OD).
 Diabetes under insulin therapy.
 Feeling of weakness, difficulty in walking for 3 days.
 The patient was a known case of Hypertension for 6 months.
 He had CVA ( Cerebral vascular accident) before 6 months, he
got weakness of right limbs after CVA.
 No history of COPD.
 No history of any surgical illness.
 No history of drug and food allergies.
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 The patient is happily married , has 2 sons and a daughter.
 There is no history of Diabetes, HTN, Asthama Or TB in famiy.
 Is a middle class family.
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Smoking:- No
Alcohol:- No
Food habbit:- 3 times a day, Non-vegetarian.
Bowel an bladder :- Regular and normal.
Sleep :- 8 hours at night.
Characteristics of the general status: overall health,
weakness, fever, weight loss, presence of edema (localization,
time of appearance, etc.).
The review should be started from the system which
desturbances predominated in the clinical manifestation of the
disease.
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Pain (dolor) in pericardial zone: No pain on palpation.
Palpatation : Non- tender.
Shortness of breath (dyspnoe): NO.
Edema (edema): NO
1. Breathing quality assessment:- NORMAL
2.
Cough (tusis): NONE
3.
Sputum (sputum): NONE.
4.
Shortness of breath (dyspnoe) and suffocation (astma.
asphyxia): NO.
5.
Pain (dolor) in the chest: NO
6.
Hemoptysis (haemoptoe) (blood spitting): NO.
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Fever (febris):- NO.
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Voice: normal.
Pain: NO
Appetite (orexis): Increased appetite .(Polyphagia )
Diarrheal effects: No
. Dysphagia (dysphagia) -No.
Abdominal bloating (metcorismus):- No
Excrements (liming) (feces), Normal.
Constipation (obstipatio):- NO.
diarrhoea (diarrhoea):- No .
1. Pain: NO;
2. nature of urination: Frequent urination with daily volume of
more than 3 litres, Polyurea,
3. colour of urine : straw-yellow, , urine turbid with trace of
suger
4. the presence of blood in the sediment:- Nil
5. assessment of urine smell:- Fruity smell;
6. Edema:- No.
1. Headache: Mild headache
2. Dizziness: dizziness and difficulty in walking, uncoordinated
gait
3.
4.
5.
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Loss of consciousness: No.
Memory :-normal,
The mood- Anxious,
job satisfaction :- okay, retired .
aggression :- sometimes aggressive usually due to poor
relation with elder son.
1. The pain :- No
2. change of gait:- uncoordinated gait.
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3.
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stiffness in the joints, morning stiffness in movements,
tremor of limbs, convulsions:- No.
Muscle strength:- weak muscle power in right limb.
Sensory:- Normal.
 Overall condition: Moderate.
 General appearence of the patient:- Anxious
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Consciousness: clear, .
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Facial expression: normal, Gait: slow, spastic, paretic,
ataxic, fast, etc.
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Posture: direct.
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Body type: type asthenic), height:- 172 cm, weight:- 90 kg
waist circumference:- 40 inch
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Skin: color - Hyperpigmentation(Shin spots)humidity (normal,
dry, wet), humidity of palms, sweating general or local
anesthesia (indicate the degree (mild, strong) and time of
appearance), skin turgor (saved, increase, decrease).
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Visible mucous: Normal
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Skin appendages: normal hair growth.
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The hypodermic cellulose: presence of fat on waist and
belly area.
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Edema: Absent.
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Head: normal shape , size and hair growth, without any
injury.
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Eyes: Absence of any discharge or readness, but Vision is
Blurry
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Nose: Normal shape an breathing without any discharge or
disturbence of smell.
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Neck: normal shape with normal mobility . Lymph nodes: no
enlaregement with normal mobility.
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The muscular system: Satisfactory muscle development,
muscle weakness in right limb.
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Bone system: Normal
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Joints: Normal
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 Examination of the chest.
1. Static inspection. The shape of the chest: normal (
asthenic), with symmetry.
 2. Dynamic examination. Symmetric motion of both halves of the
chest in breathing,:- normal.
 the number of respiratory movements per minute;:- 16 ,
 type of breathing:-combined,
 Rhythm:-rhythmic
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 Shortness of breath: Absent,
 Palpation of the chest: No tenderness or mass found.
 Percussion of the chest: Resonant on all lung field
 Lung auscultation: normal vesicular breath sound on both
sides
Of The Sternum _________________________________
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____________________________________________________________________
__
Left
Midclavicular Line.
____________________________________________________________
– __120 Beats____Per 1 Min,. (Ir)Regular____
Filling___Normal____________,
Strain____High_____________,
Contour_____Visible_________, (Un)Equal On Both Arms.
Arteries Palpation And Auscultation_____Pulse Is Prominent
Bp On The Left Arm__140/90__________Mm Hg, On The Right
Arm_140/90____________Mm Hg..
tive. Central Venous Pressure___6mm
Of Hg_________
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 Inspection:- No abdominal distention, symmetrical movement of
abdomen with respiration, do dilated superficial veins, no scar
marks.
 Palpation:- Non- tender
Normal liver and spleen
 Percussion:- Dulness present.
 Ascultation:- Bowel sounds present(Normal)
 Lumbar area examination: No tenderness or mass found,
 Pasternatskiy symptom (on both sides):- Negative,
 palpation along the renal ducts (detection of points of pain):no pain;
 palpation and percussion of the suprapubic section (bladder)
:- no tenterness or mass found,
 Gynecomasty:- no
 Scrotum, testicles:- normal without tenderness or any
abnormal mass.
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the pateint is well
oriented in time and space
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good ,
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- have some family issues ,
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finds
difficult to control his emotions .
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had
conflict with elder son,
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slightly hot temered, its persistence and pattern.
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thyroid gland, its swelling:- normal ,
without tenderness ; thyroid dysfunction symptoms :- none ,
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
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Stroke
Cardiovacular embolism
Diabetes
Diabetic retinopathy
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Hematoogical:BSR- 210 mg/dl.
Sodium- 139 mg/dl
Potassium:- 4.6mmol/dl
Creatinine:-1.0 mg/dl
Blood urea:-30 mg/dlgm
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:- light yellow
Acidic
Nil
trace
Clear
0-2 /HPF
- 0-2 /HPF
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:- 8.2 mmol/L
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11.5 mmol/L
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6.8 %
For suspiscion of diabetic retinopathy following tests were
performed
 Fluorescein angiography- some microvessels were seen to be
blocked.
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 Optical coherence tomography (OCT)
Based on all the gathered information , Diebetes mellitus
has been diagnosed in this patient with the complication of
diabetic retinopathy.
 Inj. Human insulin -3.o.7ou
 Amlodipine 5 mg OD continue
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Lifestyle modification:- exercise, healthy diet
Diabetic diet
Regular blood sugar level monitoring
Regular eye check up
Diffrent site of injection
Foot care.
- as this is a chronic condition,
with diet modification and lifestyle changes combined
with insulin therapy, the prognosis is good and person
can lead a normal life with proper health
monitoring);
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2.
usually 70 % of the population is not
at fatal risk , only in severe untreated the person
may die due to diabetic ketoacidosis and other
cardiovascular diseases.
3.
person can do daily works with
some limitations if severe obesity is present.
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