47yr old male came unresponsive since early morning

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. 



I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  
CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.


CHIEF COMPLAINT
47 yr male patient came with c/o Unresponsiveness since early morning and Burning micturition since 3 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic upto 5 am then he became unresponsive , patient was brought to casualty with GRBS 35 mg/ dl
After inj. 25D 100ml iv/ stat Grbs was 168 mg/ dl , patient became responsive.
The patient had burning micturition since 3-4 days .
He had similar complaints 1 week ago . Patient came to casuality with hypoglycemic episode.
He had fever,vomitings which was non projectile type and non bilious with food content and had loose stools.
He had 3 episodes of loose stools on 19/06/2023 morning
No sob, chest pain, palpitation,weight loss
He had increased frequency of urine output since few days.
PAST HISTORY 
 Diabetic Mellitus-II since 10 years on regular medication.
No HTN,CAD,Asthma,TB, thyroid disorders
No blood transfusions
Patient had Cataract surgery 10 years back.

FAMILY HISTORY
No significant history

PERSONAL HISTORY 
Married 
Driver by occupation,stopped working since 6months 
Mixed diet
Decreased appetite 
Adequate sleep 
Burning micturitiom since 3 days 
No constipation 
Loose stools since 19/06/23
Normal bowel
No known allergies
Patient is chronic smoker, 2 packets per day since 20 years and 
Since 6months reduced smoking to 2 to 3 cigarattes si & takes occasionally Alcohol 

GENERAL EXAMINATION
 conscious ,coherent , cooperative 
Lean built 
Pallor present 
No icterus,cyanosis,clubbing of fingers,lymphadenopathy,pedel edema

 

VITALS
Pulse rate -84bpm.
Bp-110/60mm hg 
RR-20per min
Temp: febrile

SYSTEMIC EXAMINATION

ABDOMEN EXAMINATION
Inspection:
Shape is scaphoid
9 quadrants are normal on inspection 
Burn scar on left lumbar quadrant
No enlarged veins 
No discolouration
No mass 
No swelling 
No striae 
Palpation
9 quadrants are normal 
No tenderness 
No mass 
Liver and spleen not palpable 
No organomegaly 

Percussion
No fluid thrills 
No shifting dullness 
No organomegaly

ASCULTATION 
tympanic type of sounds 
Normal bowel and bladder movements
CVS
bilaterally symmetrical chest
No visible pulsations/engorged veins on the chest
Apex beat seen in 5th intercostal space 
S1 S2 positive
No murmurs

Respiratory examination
Trachea is central
Movements are equal on both sides
Thoraco abdominal type of breathing
On percussion resonant on all areas
No added sounds 
INVESTIGATIONS 
18/06/23
19/6/23


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