GM Elog 6

E-LOG GENERAL MEDICINE
Hi, This is Rithika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

 A 67 YR M WITH SUDDEN DIFFICULTY IN SPEECH AND SWALLOWING

CHIEF COMPLAINTS:

• No speech since 3 days
• Difficulty to swallow since 3 days
• Not passing urine since 2 days

HOPI:

• Pt was apparently asymptomatic 25 yrs ago, when he developed HTn and DM and since then is on treatment for it. 
• Later, 10 yrs ago, he developed SOB, pedal edema for which he was diagnosed with a heart problem and got opersted with 3 stunts. 
• Again 4 yrs ago, he developed glaucoma in both of his eyes, for which he got operated for both eyes. One eye's vision got rescued . 
• 1 yr ago he also suffered from covid and got cured. 
• Since Jan of this yr, he developed high creatinine levels, sleep disturbances, got diagnosed with kidney disease and since then is on dialysis and frequent blood transfusions. 

PAST HISTORY:

• HTn and DM since 25 yrs and is on medication ( Initial 10 yrs on OHA and from then after stents, mrng 20U and evng 20U of insulin) 

PERSONAL HISTORY:

Sleep inadequate
Appetite decreased(  can't eat due to the nausea accompanied by the odour of dialysis) 
Mixed diet ( vegetarian since 6mnths due to the nausea) 
Alcohol- stopped since 3 yrs
Smoking stopped since 15 yrs

FAMILY HISTORY:

Nil significant

GENERAL EXAMINATION:
Oedema of feet - present
Nil significant

VITALS:

Pulse - 94
RR- 20cpm
BP - 150/100mmHg
SPO2- 100
GRBS - 233
Temp - afebrile

SYSTEMIC EXAMINATION:

CVS:

S1, S2 heard
No thrulls and murmurs

RS:

No dyspnoea, wheeze
Position of trachea - central
Breath sounds - vesicular

P/A:

Shape - scaphoid
No tenderness, palpable mass, bruits, free fluid
Hernial orifices normal

CNS:

LOC - stuporous
Speech - no response
No signs of meningeal irritation
GCS - E4V1M6

PROVISIONAL DIAGNOSIS:

Altered sensorium


INVESTIGATIONS:








TREATMENT:

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