GENERAL MEDICINE BLOG 5

July 21 2022 
A 55 Year OLD MALE PATIENT . AGRICULTURE BY OCCUPATION CAME WITH THE DECREASED URINE OUTPUT AND DECREASED RESPONSIVENESS

Hi, I am G soniya 3rd sem medicalstudent.This is an online elog book to discussour patients health data after taking her consent.This also reflects my patient centeredonline learning portfolio.


Chief complaints:
A 55 year old male patient agriculture by occupation came with the chief compliant of DECREASED URINE OUTPUT since night and decreased responsive ness

HoPI: 
Pt was apparently asymtomatic 10 years ago then he started consuming alcohol occasionally during festivals  then he gradually increased in quantity of consuming alcohol intake every day

Pt doesn't experience any sleep disturbance or tremors or palpitation if he doesn't consume  alcohol

 At5 years back   he  taking excessive amount of alcohol in night which is denoted by pt personal stress

Then he stopped food intake since 3 days 
And continues bring alcohol since 3 days
Decreased urine output since 1 day
Decreased responsive ness since 1 day
Pt was not talking but opening eyes
No history of blood or stool vomiting
No h/o head injury or seizer 
No h/ o loss of interest or easy fatigibility

Past history: 

No significant psychiatric illness in the past 
No dm htn asthama
Personal history; 
Diet mixed
Appetite lost 
Bowel regular
Micturation decreased
Addiction alcohol intake r
 No family history 

No psychiatric illness in the family history

No drug history

Physical examination 
No paller
No icterus
No cyanosis
No clubbing of fingers
No pedal edema
No lymphadenopathy
Dehydration mild
PR 106
RR 18
BP 120/80
Spo2 99
GRBS 22
Systemic examination
Cvs: 
No thrills
Heart sounds S1 S2 heard
No murmers
RS :
No dyspnoea
Position of trachea central
Breath sounds vesicular
Abdomen;
Shape of abdomen scopoid
No palpable liver 
No palpable spleen
No free fluid
CNS;
Conscious
Speech abnormal
Reflexs    biceps  triceps  supinator knee
Right.          ++.         ++.         ++.         ++
Left.             ++.      ++.         ++.            ++

Central signs
Finger nose coordination 
Knee heel coordination 

 Daignosis; alcohol caused hypoglycemia 

Medication 

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