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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment

A 65 year old male, resident of nalgonda, farmer by occupation presented to the casualty with

CHIEF COMPLAINTS -- 
1. Loss of consciousness, not waking up from the bed
2. Weakness in the body since 20 days
3. Loss of speech since 20 days 

HISTORY OF PRESENT ILLNESS 

The patient was apparently symptomatic 4 YEARS back when one day he collapsed beside the bed at 2:00 a.m. in the morning when he woke up to use the washroom 
He complained of feeling giddiness which caused the fall. He was put back in the bed by his wife.
Next day morning when he woke up he fell down the bed again due to malaise and weakness in his Limbs, he was conscious and responding well 

Upon consulting an RMP he was given glucose and 2 injections 
Futher they consulted another doctor, where he was diagnosed with diabetes mellitus and hypertension and was given medications for the same 

He has been frequently visiting the same hospital and getting medications once every week or once every 2 weeks

3 YEARS back he was admitted in a hospital due to high fever, diagnosed to be dengue as stated by his wife
The patient was apparantly warned about his kidney being damaged during his frequent visits, which he didn't share with his wife. 

30 days back, the patient started scolding and screaming at his wife at 4 am in the morning, but his speech was not clear
He was taken to a nearby hospital where they were told that his blood pressure is high and blood glucose level is low
He was treated and sent back home 

7 days back he has visited our hospital with complaints of not being able to walk properly since 3 days, and he was asked to come the next day 

The next morning he was unconscious and didn't wake up from his sleep, and was brought to the hospital in an ambulance 

HISTORY OF PAST ILLNESS 

Umbilical hernia since birth/childhood? 

He has complained of having back pain since 3 years for which he occasionally took medicines

He had constipation since 6 days before being admitted at our hospital

DAILY ROUTINE
 
Before illness:

Wakes up at 5am
Roams around the village
Reaches the home at 7 
Has tea
Goes for work, daily labour work or farm
Comes back at 10 to have breakfast 
Goes back for work and comes at 1pm for lunch
Goes back to work at 2
Comes back in evening or night at flexible times 
Has dinner at 8 and sleeps

After illness;

Wakes up at 6am 
Has tea and breakfast 
Takes rest
Has lunch with wife
Sleeps for a while
Washes his clothes at 3pm 
Shifts the wooden sticks from outside the house 
And further has dinner and sleeps


PERSONAL HISTORY 

sleep normal

Appetite lost since 20days (does not eat vankay,gongura,potato)

Bowel movements- occured twice since the 20 days before he came here

Bladder normal

Allergy nill

Addictions nill, occasionally drinks alcohol 


FAMILY HISTORY 

 Brother has history of Diabetes 

TREATMENT HISTORY 

Has been on oral hypoglycemic drugs and antihypertensives since 4 years



GENERAL EXAMINATION 

Patient was concious coherent oriented to time and place
Moderately built and moderately nourished

Pallor present 
Icterus NO
Cyanosis NO
Kolionychia NO
Lymphadenopathy NO
Edema present 




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