A 65 year old male, known diabetic and hypertensive for last 10 years, presented with presenting complaints of deteriorating vision in right eye for the last 6 years, weakness of left side of body for the last 5 months, polyuria and weight loss for the last 3 months.
History of Present Illness
Deterioration of vision in the right eye was gradual, progressive and painless for the last 6 years. Weakness of left side of the body developed 5 months back suddenly when he woke up one morning. This weakness was widespread and associated with numbness and unsteadiness. There was no history of trauma. There was progressive increase in frequency and volume of urine for the last three months, associated with increased thirst. Patient also complained of nocturia. Marked weight loss of 7 kilograms had occurred gradually over the last 3 months.
Past and Personal History
The patient suffered from pulmonary tuberculosis 7 years back. He was also a smoker but quit smoking 10 years ago.
Family and Drug History
The patient also had a positive family history of diabetes and hypertension and had been taking tablet Metformin and tablet Amlodipine for the last 10 years.
The patient was of low income group and lived in a house that he owned in a nearby village.
In a patient with history of diabetes a complete head to toe examination is performed to find out any underlying complications starting from vitals, examining the hands , the skin, neck, head so on and so forth.
General Physical Examination
The patient was an average built man, sitting comfortably on a chair, well oriented in time, place and person, not apparently in pain/respiratory distress. His pulse was 86 bpm, blood pressure 150/90 mmHg, respiratory rate 17/min and temperature 98 F.
Pallor, clubbing, koilonychia, leukonychia, cyanosis and edema were absent, JVP was not raised and lymph nodes were not palpable.
During examination the patient was fully conscious and alert but showed left 7th cranial nerve paresis of the upper motor neuron type. Rest of the cranial nerves were intact. There was also left hemiparesis with reduced muscular power of 2nd and 3rd grade with up going planters.
Gastrointestinal tract examination showed no abnormality and the bowel sounds were present. Similarly respiratory system and cardiovascular system examination was unremarkable.
Dot blot hemorrhages and hard exudates were seen on fundoscopy.
The blood complete picture showed no abnormality. However the glucose profile was deranged showing a raised fasting glucose level of 9.6 mmol/l (normall value 3.3 – 6.1 mmol/l), Plasma glucose 2 hrs A.F.B 14.7 mmol/l (normal value 3.3– 7.6 mmol/l) and random plasma glucose 15.1 mmol/l (before lunch) while 24.1 mmol/l (after dinner)(normal value 3.3–11.1 mmol/l).
In urine routine examination glucose was ++. Renal function tests showed serum urea 20.1 mmol/l (normal value 2.5 – 7.6 mmol/l) and serum creatinine 127 mmol/l (normal value 62 – 115 mmol/l). Creatinine clearance was 23 ml/min (ref range: 80-140 ml/min). Urinary ketones were not present.
Urine protein excretion rate was also performed and proteinuria was found in traces by dip stick method. Renal scan showed bilaterally impaired functioning kidneys (chronic renal failure). Liver function tests were normal, lipid profile was normal, echocardiography revealed mild diastolic dysfunction. Doppler ultrasound showed mild diastolic dysfunction with ejection fraction of about 50%.
On the basis of above mentioned history, examination and investigations a diagnosis of non insulin dependent diabetes mellitus with diabetic retinopathy, diabetic nephropathy and CVA (rt) was made.
Clopidogrel is antiplatelet drug given to inhibit blood clot formation (75mg OD). Atorvastatin belongs to statins, antihyperlipidemics (20mg OD), amlodipine is calcium channel blocker, a anti hypertensive drug (5mg OD in morning). He was also advised tab Aspirin (75mg OD) and Inj Humulin 70/30 (22 units in morning with breakfast and 14 units at night with dinner).
Non Pharmacological Management
The patient was advised regular physiotherapy, low salt diet and diet restricted in potassium (bananas, juices, tomatoes, pulses).
The patient was advised follow up after 2 weeks and was stabilized on insulin. After 2 weeks the patient reported to the OPD and a blood glucose profile was performed showing controlled plasma glucose well within normal range.