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.
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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



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