39 G Sadhguna
July 10 ,2022
General medicine elog
Hi , I am G Sadhguna ,3rd semester 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 portfolio.
A case of 71 year old male patient resident of Nalgonda district came to OPD with complaints of with cheif complaints of slurring of speech.
History of present illness
Patient was apparently asymptomatic 3 days back.
Slurring of speech was observed in the morning and immediately came to the hospital.
No headache
No chills and regors
No fever
No body pains
Past History
Hypotension since 20 years
Type 2 Diabetes mellitus since 20 years on insulin(2 times per day)
Left below knee amputation 5 years ago due to diabetic foot
N/K/C/O CAD, Epilepsy,TB,Asthama.
Personal History
Appetite normal
Diet mixed
Bowel and bladder movements normal
Sleep adequate
Addictions - 10 years back patient used to drink Toddy and Sara occasionally.
10 years back used to smoke ciggerate (7-8 per day)
Atpresent no addictions
Family history
Not relavant
General Examination
Not conscious and cohorent
No pallor, icterus,clubbing of fingers,cyanosis, lymphadenopathy,pedal oedema.
Vital Signs
Pulse rate - 86bpm
BP - 120/90 mmHg
Respiratory rate -
Comments
Post a Comment