Имя: G.D.K.U.K Jayaratna
Возраст: 52 года
Диагноз: 1. Диабет 2 типа; 2. Диабетическая ретинопатия; 3. Диабетическая нефропатия 4. Гипертония 2 степени; 5.Атеросклеротический кардиосклероз
Длительность лечения: 24 дня
The patient suffered from diabetes for 10 years. He took melbine and inject Novolin 30R 50iu each day. The blood sugar wasn’t under control. The FBG was 7-10mmol/L and postprandial blood sugar was 13-18mmol/L. The patient had coronary heart disease for 7 years and took medication for therapy. He had hypertension for three years and took different kinds of medications to control the blood pressure. But his blood pressure still not go under control. The blood pressure was between 130-180/85-100mmHg. He had kidney failure for 6 months. The laboratory test showed blood BUN and Creatinine were higher than normal obviously. The patient had diabetic retinopathy and glaucoma for 7 years. He had repeatedly fundus retinal hemorrhage and vitreous hemorrhage. He received an operations, both his eyes vision decline obviously. At present, his right eye only presented light sensation. Left eye bitamporal still has weak vision. Left eye could see big object move from 1 meter distance. He couldn’t distinguish the number of fingers and couldn’t distinguish colors.
Bp: 150/95mmHg，Hr:83/min, Br 19/min. The patient had normal body type and development. The skin was dry, with no petechial or yellow stains. The thorax was symmetrical. The respiratory sounds in both lungs were clear, with no moist rales. The heart sounds were strong, the cardiac rhythm was regular, and there was no obvious murmur in the valves. The abdomen was enlarged. The liver and spleen were found to be normal through palpation.
G.D.K.U.K Jayaratna was alert and his speech was clear. The memory, orientation and calculation abilities were normal. The diameter of both pupils was 3.0mms. The eyeball of his right eye was milky white and the pupil was unable to be observed. The response of left eye to light was slow and the right eye had only the perception of light. Vision was present in the left eye but sees big objects moving in one meter away. He was unable to distinguish color. Both eyes could move freely to each side. He had no nystagmus. Eye fundus examination: Left eye: the color of optic disc was pale yellow. The arteriovenous ratio was out of normal. The arteriovenous ratio was 1:5. The equator of the eye has a plenty of black pigments. The physiological cup could not be seen. The retinal boundary of macula region was not clear. In the right eye, the cornea and lens had physiological change and the eye fundus could not be observed. The forehead wrinkle pattern was symmetrical. The nasolabial sulcus was equal in depth. The teeth were symmetrical. The tongue was at the center of the oral cavity. The neck could move freely. The muscle tone of his four limbs was normal. The muscle strength of his four limbs was about level 5. The abdominal reflexes were weak. The tendon reflex of bicipital muscle and triceps muscle of arms, and the patellar tendon reflex and achilles tendon reflex could not be elicited. Bilateral Hoffmann sign was negative. The pathological reflex of both lower limbs was negative. The deep sensation and shallow sensation existed. The examination of coordinate movement was normal. The sign of meningeal irritation was negative. Laboratory test showed: blood urea nitrogen 13.09mmol/L, serum creatinine 271umol/L, PRO 2+. The level of homocysteine has increased.
We gave G.D.K.U.K Jayaratna a complete examination and he was diagnosed with 1. Type 2 diabetes; 2.Diabetic retinopathy; 3.Diabetic Nephropathy 4.Hypertension stage 2 5. Coronary atherosclerotic cardiopathy Hyperhomocysteinemia. He received treatment for tissue repair, nerve regeneration and stem cells activation. He received treatment to expand the blood vessel, to improve the blood circulation in order to increase the blood supply and nourish the damaged neurons. He also received treatment to lower his blood pressure and blood glucose. This was accompanied with daily physical rehabilitation training.
The patient’s blood pressure and blood sugar are under control. At present, his blood pressure is between 110-135/65-85mmHg. He has stopped the oral hypoglycemic drug and reduced the insulin dosage (Novolin 30R reduced from 50iu to 40 iu). The blood sugar is under control and the level is stable. Fasting blood-glucose (FBG) level is stable between 4.2-6.0mmol/L. 2-hour post-meal blood glucose level is between 8.0-11.0mmol/L. The laboratory showed the renal function index is reduced than before. Creatinine has reduced from 271umol/L (admission) to 207umol/L. The urine protein has reduced from 2+ (admission) to trace. Urea nitrogen has reduced from 13.09mmol/L to 8.60mmol/L. The HCY level has been restored to normal level. During his stay in the hospital, the patient’s left vision suffered from a transient decline and lasted for two days, the patient’s left vision was restored to normal level. Fundus examinations: Under ophthalmoscope: left eye: optic disk present orange color. The blood circulation is better than before. The exudation is reduced than before. The proportion of artery and vein is 1:3. The black sediment in equator peripherals has reduced. There is no edema in optic nerve head. The border of macula lutea is clear.