65 yr old male with IMSC GR 1-2 IN BOTH EYES WITH IMPACTED WAX IN RIGHT EAR
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 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 inputs on the 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.
C/O abnormal stream of urine since 1 yr
C/O blurring of vision and binocular double vision in both eyes since 5-6 months
HOPI
Patient was apparently asymptomatic 1 yr ago when he developed abnormal stream of urine.
Pt C/O feeling of residual urine after voiding. Urine falls close to the patient.
No C/O dribbling of urine, graveluria, prev. Catheterization, increased frequency of micturition.
C/O blurring of vision in both eyes since 5-6 months
No H/O trauma to eye/head
C/O binocular double vision since 5 months
- only on seeing bright light
- not present throughout the day
C/O dryness on left ear since 2 months
No H/O ear fullness, ringing sensation, discharge, dizziness, frequent URTI
Patient had fluctuation of BP since 2 months ( denovo HTN and not on medication)
N/K/C/O DM, Thyroid disorders, Epilepsy, BA, TB, CVA, CKD
PAST HISTORY
H/O surgery for oral carcinoma 10yrs back
H/O radiotherapy for oral carcinoma
H/O surgery for fistula in ano 3 yrs back
PERSONAL HISTORY
Patient used to consume alcohol 10 yrs back. (90ml/day for 25yrs)
Patient used to smoke cigarettes 10 yrs back. (2 packs/day for 25 yrs)
Patient chewed tobacco 10 yrs back. ( everyday for 25 yrs)
TREATMENT HISTORY
Pt is taking TAB. URIMAX D since 1 month
PHYSICAL EXAMINATION
No Pallor ,Icterus, Cyanosis,Clubbing ,Lymphadenopathy
TEMPERATURE - AFEBRILE
PULSE RATE - 48 BPM, regular rhythm, normal volume
RR-18 CPM
BP- 150/90 MM HG
SPO2- 98 % AT RA
GRBS - 72 MG/DL
SYSTEMIC EXAMINATION
CVS - S1 ,S2 heard , No murmurs
RS - BAE +
P/A - Soft ,Non tender
CNS - NAD
BP monitoring
11/2/22
9 a.m. 160/100 mm hg
2 p.m. 140/100 mm hg
4:30 p.m. 170/90 mm hg
8:45 p.m. 130/70 mm hg
11 p.m. 130/60 mm hg
12/2/22
7:30 a.m. 140/70 mm hg
ENT Referral
Ophthalmology referral
Pulmonary medicine referral done i/v/o radiation induced fibrosis
INVESTIGATIONS
Chest X Ray
Report:
Prominent hila with no significant changes
Usg abdomen
Report:
Prostate 27 cc increased with grade 1 prosatomegaly with no significant PVR
CBP
Hb : 11.4 g/dl
TLC : 6000/cu.mm
Platelet : 1.22 lakh/cu.mm
RFT
Urea : 3.2
Creatinine : 0.9
Uric acid : 6.7
Ca : 10.2
P : 2.3
Na : 144
K : 3.9
Cl : 102
HbA1c 6.5%
PPBS 102 mg/dl
PROVISIONAL DIAGNOSIS
IMSC GR 1-2 IN BOTH EYES WITH IMPACTED WAX IN RIGHT EAR
TRAETMENT GIVEN
1. WAXONYCLEAR drops 4 drops × 4 times/day
2. BP monitoring 4th hrly
