GM case-01

August 17,2022


Hi, I am P.Aishwarya , 3rd sem medical 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.
CASE SCENARIO:
CASESHEET:

Chief complaints:
generalised weakness and drowsiness since the past 15 days.
fever since 10 days.
vomiting since 10 days.

HISTORY OF PRESENT ILLNESS:
Asymptomatic 1 year ago and then developed involuntary movements of both upper limb and lower limb with rolling of eyes for which he was taken to hospital and diagnosed to be having alcoholic encephalopathy.

Patient's sodium level decreased and was admitted to hospital for further investigations and was conservatively further investigated.
 
He was asymptomatic until 10 days back.

But again developed low grade fever relieved with medication, generalised weakness and episodes of emesis twice a day containing food particles, acid content associated with nausea.

ASSOCIATED DISEASES:
__________

PAST HISTORY:
h/o alcoholic encephalopathy with seizures 1 year back.

Not a Known case of 
No Diabetes Mellitus (DM)
No Hypertension (HTN)

Similar episodes 1 year ago.

PERSONAL HISTORY:

Normal appetite with Regular Bowel movements. 

Has normal micturition with no burning sensation.

Has no allergies

chronic alcoholic with gutka usage.

FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.

DRUG HISTORY:

GENERAL EXAMINATION:
No pallor
No cyanosis 
No lymphadenopathy
No icterus
No edema of feet
No clubbing of fingers
 Malnourished.
Mild Dehydration
Temp - 98.6°F
GRBS - 84mg%

VITALS:
Temperature: 

Pulse: 16 beats per minute

Respiratory rate: 16cycles per minute

Blood pressure: 9070 mm of Hg

SPO2:98 at room temperature.

SYSTEMIC EXAMINATION :

Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 heard

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

CENTRAL NERVOUS SYSTEM :

Drowsy awaken on arousal
Speech: Delayed response 

INVESTIGATIONS:
Biochemical investigations:
   
ECG:
PROVISIONAL DIAGNOSIS:

Metabolic encephalitis 


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