68 yr M with sudden difficult in speech and swallowing
I am Soumya 5th semester 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
CHEIF COMPLAINTS
• No speech since 3 days
• Difficulty to swallow since 3 days
HISTORY OF PRESENT ILLNESS
• 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.
HISTORY OF PAST ILLNESS
• 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:
Thrills: no
Cardiac sounds:S1 ,S2 present
Murmurs : absent
RS:
Dyspnea: No
Wheeze: No
Position of trachea: central
Breath sounds: vesicular
Abdomen
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
PROVISINAL DIAGNOSIS
Altered sensorium
INVESTIGATIONS
28/8
30/8
31/8
DIAGNOSIS
CKD on MHD
K/c/O HTN and DM since 25 years and CVD /CVA
HFrEF
Decreased sensorium under evaluation
TREATMENT PLAN
28/8