A 60 year old male came to general medicine OPD with the chief complaints of unresponsive state

29/12/22 

General medicine elog 

Hi , I am K.Sai Rithindar Reddy,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. 

CHIEF COMPLAINTS:  

A 60 yrs old male who is daily wage worker by occupation resident of sangaram came to casuality with chief complaints of unresponsive since yesterday night . 

HISTORY OF PRESENT ILLNESS: 

patient was apparently asymptomatic 10 yrs then he developed Diabetes Mellitus 2 patient was on insulin 
4 yrs back patient developed giddiness & while working patient had fracture in Right upper limb & Right lower limb 
2 yrs back patient developed similar episodes of altered sensory & hyperglycemia 
10 days back patient developed swelling on lower limbs & ulceration on right toe for which he was diagnosed with diabetic foot & treated with antibiotics. 

PAST HISTORY  : 

K/C/O DM since 10 yrs & BP since 4 yrs 
N/K/C/O Asthma,TB, Epilepsy 

FAMILY HISTORY :

No significant family history 

PERSONAL HISTORY :
Mixed : Diet 

Appetite :normal

Sleep : adequate

Bowel and bladder movements-regular

Occasional drinker & ciggerate but stopped drinking since 10 yrs  

GENERAL EXAMINATION: 

Patient is conscious,coherent and cooperative

moderately built and well nourished

No pallor  

No icterus 

No clubbing of fingers

No cyanosis 

No Lymphadenopathy

Pedal edema absent 

VITAL SIGNS : 

BP-130/80mmhg

Pulserate- 64 bpm

SpO2 -97%

SYSTEMIC EXAMINATION: 

CVS: 

S1 and S2 sounds heard 

No murmurs

No thrills 

RESPIRATORY SYSTEM:

No dyspnea

No wheeze

Central location of trachea

Vesicular breath sounds 

ABDOMEN:

Abdomen is distended 

No tenderness

No palpable mass 

Normal hernial orifices 

Non palpable liver and spleen

Bowel sounds are heard 

CNS: 

Conscious 

Speech- slurred 

Signs of meningeal irritation - 

no neck stiffness

no kerming's sign

Cranial system - intact 

Motor system - intact 

Sensory system - lost 

INVESTIGATIONS: 

ECG : 
PROVISIONAL DIAGNOSIS: 

Altered sensorium 


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