75 Year old Gentleman with Type 2 Diabeties Mellitus

This is the case of a 75 Year old gentleman , resident of hyderabad . This case report aims to record the Patient's Journey . 

This record was created by taking inputs from the patient via a telephonic conversation and from the WhatsApp conversation with the patient advocate dated - 21st June 2022.

History Of Presenting Illness

The patient was apparently asymptomatic 37 years ago . 

37 years ago, the patient explains an episode of jaundice , due to which the patient had to take rest for 6 months. Since then the patient complains of stomach pain, gas, burning sensation which occours 2 to 3 times a month and lasts about 3 days .(source - whatsapp conversation)

9 years ago, the patient was suffering from hemorrhoids which were not getting cured even after treatment. On further evaluation, the patient had a elevated blood sugars and was thus diagnosed with Diabeties Mellitus Type -2.The patient was started on Metformin and glippizide for 3 months. Slowly the hemorrhoids were cured on treatment. 

The three following years, the patient had followed a low carbohydrate diet. The diet helped in reducing acid reflux and sugar levels. 

6 years ago, the patient had difficulty breathing and was taken to the hospital . An angiogram was done , it depicted a 60 per cent block in an artery, which was managed medically . The medicines prescribed included 

• Cardiovas 3-125 mg 
• Clopitab 75/10 mg 
• Ankit 0.5 mg 
• (List of drugs taken from WhatsApp conversation)

3 years ago, the patient experienced chest pain and was rushed to the hospital, the angiogram did not reveal any block in the artieries. It was concluded that the patient had gastritis that led to the chest pain. The following medicines were prescribed at that time.

• Cardivas 
• Clopitab
• Nexpro
• Glyciphage
• Pregaba
• Augmenting
• Uprise
• Atorvas
• (List of drugs taken from WhatsApp conversation) 

Last year - bloating  of the stomach was a common occurrence (once every week), especially when the diet was irregular- the patient used to take antacids which are not currently used.

5 months ago, the patient experienced a bloating sensation and Nausea in the middle of the night, which lasted 2 hours and relieved on its own . The following night the patient had a similar episode. On consulting a doctor, the following medicines were prescribed. 

• Rifagut 550
• Sometthicone capsules. 140 mg 

The patient also consulted a gastroenterolgist. On endoscopy and colonoscopy - esophagitis and hemorrhoids were diagnosed.

The following medicines were prescribed(source :WhatsApp conversation)

• Esomiprazole 40
• Pruease 

The patient also had mild joint pain and stiffness for which the patient was given osteomust vitamin D3 and  etodolac 400. 

1 month ago, the patient experienced two episodes of an acute Respiratory Illness associated with fever and weakness. The patient took Paracetamol.

6 days ago, the patient experienced hemorrhoids and was given lignocaine gel . The hemorrhoids have reduced.

Past History 

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

There is no history of blood transfusions or surgeries.

Personal History 

Diet - vegetarian , intolerance to spicy food, causes acid reflux.

Appetite - normal

Sleep - disturbed, the patient wakes up at night to micturate every 2 to 3 hours 

Bowel movements- occasional constipation and hemorrhoids 

No history of addictions 

No allergies

Family history 

Mother - history of  DM 

Current medications

Clinical images -