Case: 45y/Male with c/o altered sensorium.

  General medicine v elog 1 

 

Hi , I am Aswin I, 3rd sem ki ester student.  This is an online e8log  book to discuss our patients health data after taking his consent.  This also reflects my patient centered online learning portfolio.
U

45y/Male with c/o altered sensorium

L78DOA: 19/05/2022
CC:
46y/M came with c/o drowsiness (altered sensorium) since 19/05/2022 morning,
c/o vomiting (3-4 episodes) since 2 days
Hiccups since 3 days
Burning micturition present since 10 days.


HOPI:
Patient was apparently asymptomatic 
5 days back, then patient developed c/o vomiting ,had 4-5 episodes, containing food particles,non bilious.n ki
Patient c/o deviation of mouth and giddiness since yesterday night(18/05/2022)
No c/o fever/cough/cold
No significant h/o previous UTIs
No c/o chest pains/palpitations/syncopal attacks.


Past History:
10yrs back pt had c/o polyuria and was diagnosed with Type 2 DM 10 yr back, 
h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation 1yr back i/v/o development of wet gangrene
OHAs been converted to Insulin since 2 yrs
Delayed Wounds healing present- wound healing took 2 months time to heal
3 years back pt underwent Cataract surgery.


Personal History:
Married
Appetite-Normal
Diet-Vegetarian
Bowel and Bladder - Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol- 
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.
Also 1 month on & off consumption pattern previously present.
79Vitals @ Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 101F
SpO2: 98% on RA
GRBS: 124 mg/dL.

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
Pt is having altered sensorium
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
Normal

Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs.

Clinical images:

77 in 88



I

Comments

Post a Comment

Popular posts from this blog

This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Image
Hi, I Aswin.I 6th sem medical student. This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning protofolia Chief Complaints: Bilateral loin pain since 3days. History Of Presenting Illness: Patient was apparently asymptomatic 7days back then he sustained snake bite (with Russell viper) on left ring finger while working in the fields,visited local hospital and managed symptomatically.  C/O bilateral loin pain,insidious in onset ,intermittent,gradually progressive,pricking type ,non radiating,aggravates on lying down. C/O low grade fever,Nausea and vomiting,bloating. N/C/O Burning Micturation,decreased or increased urine output. N/C/O cough,cold,body aches,chest pain. Past History: n/k/c/o diabetes HTN,Epilepsy,Tuberculosis,CAD,CVA Personal History: Diet : Mixed,  Appetite : Normal Sleep : Normal Bowel and bladder moments :Regular  Addictions: chronic alcoholic since 20years. Tobacco smokin
Read more

A 20 YRS OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF YELLOWISH DISCOLORATION OF EYES.

Image
Hi I am, Aswin (roll no:18), 5th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. Chief Complaints: A 20 yrs old male came to opd with chief complaints of Yellowsish discoloration of eyes. History of presenting illness: patient was apparently asymptimatic since one year back then developed Yellowsish discoloration of eyes  POSITIVE HISTORY Loss of appetite Irregular bowel and bladder movements Adipsia NEGATIVE HISTORY: N/K/C/O: TB , Asthma, epilepsy, thyroid PERSONAL HISTORY: Mixed diet Irregular bowel and bladder movements Adipsia No addictions Sleep adequate FAMILY HISTORY: No relevent family history GENERAL EXAMINATION: The patient was conscious, coherent , well oriented to time place person and was examined in a well ventilated room No pallor Icterus present No lymphadenopathy No clubbing of fingers Well built  Well nourished No
Read more

45yrs old male patient

Image
This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent. Shreshta.A  06 Aswin.I  18 Chief complaints : A 45 year old male driver from nalgonda was admitted in the hospital on 14th june 2022 with chief complaints of Itching sensation throughout the body and Pain in the right abdominal region since 1month. History of present illness: Patient was apparently asymptomatic 1month back, then he developed multiple lesions over lower limb. Lesions progressed to form ulcers. SOB present since 1month  Increase thrist and urine output (14 to 15 episodes of mixturation),increase bowel movements since 1week Frequently coughing (sputum) while talking Fever: persisting since 1 week             Chills and rigor              Cough and cold Felling nauseous. Past history:  Not diabetic  No hypertension  Did not undergo any surgery  Not on any medications. Family history: Not relevant.
Read more