Case Write Up

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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 modification

Cardiovascular System:
Mr. X had no dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, chest pain, palpitation, ankle swelling, claudication of the lower limbs.

Respiratory System:
Mr. X had no cough, haemoptysis, dyspnoea, wheezing or flu.

Gastrointestinal System
Mr. X had no pre rectal bleeding, malaena, dark urine, pale stool, haemataemesis, or abdominal pain.

Nervous System:
Mr. X had no history of depressed, seizures, dizziness, syncope, and vertigo. There was no change in vision, hearing or smell before this

Genitourinary System:
Mr. X had symptom such as increased frequency of urination, nocturia, polyuria intermittently due to type 2 diabetes mellitus. No dysuria and haematuria noted.

Musculoskeletal System;
Mr. X had no symptom of limitation of joint movement, gait and limping.

PAST MEDICAL AND SURGICAL HISTORY

He had diabetes since 10 years ago. He was diagnosed at private clinic in Puchong with symptoms of lethargy, polydipsia and polyuria. He was not complied with the medication at beginning and only started compliance to medication since 3 years ago. Other than that, there was no history of complication of diabetes. There was no past surgical history.

SOCIAL HISTORY

He is staying with his wife and the eldest son. He has two sons, the eldest is working as engineer and the youngest is studying in Australia. The wife is still working as clerk with monthly income of RM1000 – RM2000. Previously, he worked as lorry driver but quit. Now, he does some part time job, taxi driver with monthly income of RM1000 – RM2000. His house is at level six with no lift, so he has to climb up the stairs every day. He is not a smoker, alcohol drinker or abuse drug. He does not have any financial problem. He has no insurance towards any medical expenses. For this surgery, he got sponsored from ngo RM6000.

FAMILY HISTORY

He has strong family history of diabetes mellitus. Both of his parents had diabetes mellitus. Both of...
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