A 50 year old man presented with chief complaints of weakness and giddiness .
General medicine elog1
Hi I’m MANISHA 3rd Sem medical student. This is an online e log book to discussion out patient’s de-identified health data shared after taking his guardians sinned informed consent. This also reflects my patient centered online learning portfolio…
HISTORY OF PRESENT ILLNESS:
A 50 year old male was brought to the causality with the chief complaints of GENERAL WEAKNESS,POLYDIPSIA( increase in thirsty) poly urea
HISTORY OF PAST :
Patient was apperantely asymptomatic 1 year back. He was found to have high sugars, at a government camp at his place. He was kept on OHA’s, used for 2 months and stoped medication for 2 months ,and patient developed complents of general weakness, polydipsia,polyurea,for which he visited a private hospitals of nakharakel,found to have high sugars(uncontrolled diabetes) DM2,he started taking insulin since then. Patient also presented with FATTY LIVER .
HE IS CHRONIC ALCOHOLIC SINCE 30 YEARS…. and DM 2 from 1 year
No Asthama ,HTN, CAD , EPILEESY, HYPOTHYROIDISM
FAMILY HISTORY: Nil.
GENERAL EXAMINATION
no pallor
No icterus
No clubbing of fingers
No cyanosis
No lymphadenopathy
No diarrhoea
Temperature:98’c
Pulse rate :82
Respiration:18 /min
Bp : left arm 70/60 mm/hg ; right arm 90/60 mm/hg
Spo2 at room air 96%
Level of consciousness:alert
SYSTEMIC EXAMINATION:
CVS
No thrills,
Cardiac sounds
RESPIRATORY SYSTEM
position of trachea : central
Breathing sounds: vesicular
ABDOMEN
scaphoid
No tenderness
No palpable mass
No free fluids
No liver and spleen palpable
CNS
Conscious
Speech normal
Normal cranial ,motor ,sensory system.
No icterus
No pallor (left eye)
No pallor (right eye)
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