A 60 year old male came with decreased vision since 2 years

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A 60 year old male came to opd with-

Chief complaints- 

C/o decreasing of vision since 2 years.

HOPI- patient was apparently asymptomatic 2 years then he developed decreasing of vision in right eye, insidious in onset, gradually progressive.

On 4/10/23,  while routine examination , his BP was measured as 170/100. He was transferred from ophthalmology to general medicine I/V/O hypertension .

H/o B/L foot burning sensation and tingling sensation since 2 years.

H/o B/L knee pain since 6 months ,radiation to hips, left knee more than right knee.

Polyuria since 6months.

Lower back ache since 8 months 

PAST HISTORY-

K/C/O DM since 7 years and is on medication (glimepiride and metformin).

K/c/o HTN since 2 years and is on medication. 

K/C/O CVA since 2 years- hemiplegia of left side.

PERSONAL HISTORY- 

Diet- mixed 

Appetite- normal 

Sleep- adequate 

Bowel and bladder movements- regular 

No known allergies 

Addictions-  chronic alcoholic since 20 years, consumes 90ml per day, preferred drinking brandy and whiskey , if not available he consumes toddy around 1 litre.

Chronic smoker since 20 years, consumes one pack of Beedi per day( 20 beedis per pack) but stopped 5 years back on doctors advice.

FAMILY HISTORY- not significant 

GENERAL EXAMINATION-

patient is conscious, coherent, cooperative. Well oriented to time , place and person, moderately built and moderately nourished 

Vitals -

BP- 130/80 mmHg

PR- 92 bpm

RR- 18 cpm

TEMP- 98.2 F

NO SIGNS OF PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA.

SYSTEMIC EXAMINATION-

1) CVS- S1, S2 heard, no murmurs.

2) RS- BAE present, NVBS 

3) PER ABDOMEN- diffuse tenderness 

 no organomegaly 

4) CNS:

Higher mental functions - intact

Cranial nerves - intact

Motor examination - normal  

Sensory examination:Normal

No meningeal signs

PROVISIONAL DIAGNOSIS- 

? Diabetic nephropathy ( peripheral) with right side Immature senile cataract.

K/C/O HTN since 2 years 

K/C/O DM since 7 years.

INVESTIGATIONS- 

Hemogram-

Hb- 11.1

PCV- 32.9

TLC- 8,900

RBC- 3.85

PLT count- 2.13

RBS- 244mg/dl

Blood urea- 51

Serum creatinine- 2.6

Sodium- 141

Potassium- 4.2

Chloride- 103

Total bilirubin- 0.66

Direct bilirubin- 0.16

ALT- 14

AST- 13

ALP- 320

Total proteins- 6.2

Albumin- 3.88

A/G ratio - 1.67

CUE - 

Pus cells - 3-4

Serology- negative.

USG-5/1023

Review USG- 6/10/23

ECG-

BP and GRBS charting- 

6/10/23-

7/10/23-

TREATMENT- 

1. INJ. HUMAN ACTRAPID INSULIN SC / TID premeal 

2. TAB. AMLODIPINE 5mg PO / OD 8am

3. TAB. PREGABALIN 75 mg PO/ HS 9pm

4.RE  E/D CIPLOX QID

5. GRBS 7 PROFILE MONITORING 

6. BP monitoring 2nd hourly.