A 56 YEAR OLD PATIENT WITH TYPE 2 DIABETES MELLITUS WITH A HISTORY OF CARCINOMA BLADDER

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through a series of inputs from an 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-related online learning portfolio and your valuable inputs on the comment box.

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 to come up with a diagnosis and a treatment plan.

CHIEF COMPLAINTS:

Lower back pain since 5 years

Chest pain for 2 years

HOPI:

The patient was apparently asymptomatic 23 years ago, then he developed polydipsia, polyuria and polyphagia 23 years ago. He visited a doctor, and after further investigation (FBS - 400 mg/dl), he was diagnosed with type 2 diabetic mellitus. He started taking antidiabetic medication. The patient has a tingling sensation and blurred vision at times.

Then, the patient had an episode of hematuria 10 years ago. He was diagnosed with high-grade urothelial bladder carcinoma, without muscular involvement. He underwent surgery and was advised to follow-up every 2 years.

He was then diagnosed with hypertension 7 years ago and was given olmesartan medoxomil 40 mg.

5 years ago, the patient slipped and fell on his right side, from a terrace 8 feet above the ground. He was disoriented for 2 - 3 minutes after falling. Since then, he is experiencing lower back pain which is dull, intermittent in nature, and radiating to the front, aggravated on continuous sitting and is relieved on changing position or stretching.

He developed chest pain 2 years ago, localised to the right and left side of the sternum, dull in nature, lasting 5 - 10 minutes. He experiences 2 - 4 episodes/month. It is aggravated 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 :Intravesical BCG instillation 6 cycles were started 6 to 8 weeks after surgery

The patient is currently taking:

- Metformin Hydrochloride (Prolonged release) 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 (the patient does not recollect when he first started smoking), and currently 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