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

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    DIAGNOSIS 

    CKD on MHD 
    K/c/O HTN and DM since 25 years and CVD /CVA
    HFrEF
    Decreased sensorium under evaluation 


    TREATMENT PLAN

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