Case Write Up
IDENTIFICATION DATA
Name : X
Age : 57 year – old
Race : Chinese
Gender : Male
Occupation : Ex – lorry driver
Marital Status : Married
Address : Puchong
PRESENTING COMPLAINT
Mr X, 57 years old, Chinese gentleman with background history of type 2 diabetes mellitus for 10 years electively admitted on 21st of September from cardio clinic for Coronary artery bypass grafting (CABG) due to severe vessel blockage.
HISTORY OF PRESENTING ILLNESS
Three years ago, he had history of chest pain which was situated at left costal margin, lightness in nature, radiated to left arm, associated with decreased effort tolerance, palpitation, profuse sweating during heavy weight lifting and the pain was relieved by rest.
However, there was no history of orthopnea, paroxysmal nocturnal dyspnea, trauma, surgery done before. After that, during following up for his diabetes mellitus, he told this symptom to the doctor, and then he was referred to hospital Serdang. After series investigation done, he was diagnosed stable angina. He was having follow up at Hospital Serdang every 3 months for his stable angina and type 2 diabetes mellitus.
He had type 2 diabetes mellitus since 10 years ago, that diagnosed at private clinic. During that time, he was lethargy and had polydipsia and polyuria. OGTT was done and the result show he was having type 2 diabetes mellitus. Start from that time, he had follow up for his type 2 diabetes mellitus at government clinic. On further questioning, he was not having other complication of type 2 diabetes mellitus such as blurring of vision, kidney failure, loss of sensation at grove and stocking area.
Patient claimed that he was not very compliance to medication and he was not changing his lifestyle much after diagnosed type 2 diabetes mellitus. Only after being diagnosed stable angina, he reliseaed the scary of type 2 diabetes mellitus. He started compliance to medication and make diet modification and lifestyle
Name : X
Age : 57 year – old
Race : Chinese
Gender : Male
Occupation : Ex – lorry driver
Marital Status : Married
Address : Puchong
PRESENTING COMPLAINT
Mr X, 57 years old, Chinese gentleman with background history of type 2 diabetes mellitus for 10 years electively admitted on 21st of September from cardio clinic for Coronary artery bypass grafting (CABG) due to severe vessel blockage.
HISTORY OF PRESENTING ILLNESS
Three years ago, he had history of chest pain which was situated at left costal margin, lightness in nature, radiated to left arm, associated with decreased effort tolerance, palpitation, profuse sweating during heavy weight lifting and the pain was relieved by rest.
However, there was no history of orthopnea, paroxysmal nocturnal dyspnea, trauma, surgery done before. After that, during following up for his diabetes mellitus, he told this symptom to the doctor, and then he was referred to hospital Serdang. After series investigation done, he was diagnosed stable angina. He was having follow up at Hospital Serdang every 3 months for his stable angina and type 2 diabetes mellitus.
He had type 2 diabetes mellitus since 10 years ago, that diagnosed at private clinic. During that time, he was lethargy and had polydipsia and polyuria. OGTT was done and the result show he was having type 2 diabetes mellitus. Start from that time, he had follow up for his type 2 diabetes mellitus at government clinic. On further questioning, he was not having other complication of type 2 diabetes mellitus such as blurring of vision, kidney failure, loss of sensation at grove and stocking area.
Patient claimed that he was not very compliance to medication and he was not changing his lifestyle much after diagnosed type 2 diabetes mellitus. Only after being diagnosed stable angina, he reliseaed the scary of type 2 diabetes mellitus. He started compliance to medication and make diet modification and lifestyle