General medicine case history -7

 This is online E log book to discuss our patients de- identified health data shared after taking his or her guardian's signed informed consent hear we discuss our individual patients problems through a series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This E log book also reflex my patient centered online learning portfolio and your valuable inputs on comment box is welcome."

Date of admission: 11/03/2022

A 50 year old male patient, farmer by occupation and resident of  nalgonda presented to opd with chief complaint of generalised weakness since 1 day.

HISTORY OF PRESENT ILLNESS :

He  was  asymptomatic 5 year back then he developed giddiness and syncope (loss of consciousness)after 10 min he used to get up and walk.(3 - 5 episodes in a year from last 5years)
 On 9th march  he developed same symptom but this time when he fainted, he is not able to stand . After 30 mins, when his son reached there he supported him to stand

People who saw him while fainting reported that he got seizures, which was first time for him ( reported by his son) .

PAST HISTORY :

Patient is the known case of diabetes since 3 years, hypotension  since 2 years.
No history of epilepsy, tuberculosis.

PERSONAL HISTORY  :

Diet : mixed 
Sleep : Adequate 
Addictions : Smoking 15 beedis daily

Daily routine:- 
Daily wake up at 4 am in the morning , then he go for Cattle rearing and work in farm of his own () till 7am, at 9am he will take his breakfast (tea and rice with curry) and at 2pm he takes his lunch and finish his dinner by 9pm and goes to bed .

He use to walk 5 to 10km daily 


FAMILY HISTORY:

No significance family history 

PERSONAL HISTORY 
Mixed diet 
Smoking daily 15 beedis
Not alcoholic 


GENERAL EXAMINATION :

Injury at left ankle during his child hood so his gait was not proper
No clubbing 
No cyanosis 
No pallor
No icterus 

Percussion of abdomen -
No fluid present 
No palpable mass
Liver not palpable 

Vitals -
Temp 98.4
Respiration 18 cycles per min
Bp 160/90
Pulse 76 beats /min 

Respiratory system -
Bilateral breath sounds are not heard 
No wheeze 

CVS -
S1 and S2 are heard 
No apex beat 
No jvp seen 
No palpitations 

CNS 
conscious , coperative ,coherent 
Reflexes are normal 
Speech normal
Gait was abnormal 





Left and right eye :





INVESTIGATIONS  :



Serum electrolytes  :
Na :-140 (136-145)
K :-  4.1(3.5 - 5.1)
Cl:- 99(98 -107)

Rbs : 130 (100-160)



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