A 56 yr old male patient with hyperglycemia with anaemia


THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 


Cheif complaints 
C/o had an episode of loss of consciousness 2 days back

HOPI:

Patient was apparently asymptomatic 2days ago .then he experienced an episode of loss of consciousness which. Was sudden in onset not preceded with any headache,nausea lasted for 1 minute,no involuntary bowel bladder movements noticed,no h/o dropping saliva noted 
No h/o head injury ,vomitings,diarrhea

Past h/o:

No h/o of similar complaints in the past .
Known case of diabetes mellitus 2 months ago.patient developed swelling of legs for which when consulted a local hospital the patient found out he was diabetic.
No h/o HTN,TB ,epilepsy,asthmaCAD

Treatment h/o:
On medication for DM since 2 months

Family h/o
Not significant

Personal history:
Diet: mixed 
Appetite:normal
Sleep : normal
Bowel &bladder : regular
Addictions :patient used to consume a toddy once a month since 2 years.stopped consuming since 2 years.
While consuming ,he used to drink half liters
Allergies:none

General examination:
Patient was conscious coherent and cooperative
Pallor: present
Icterus:absent
Clubbing:absent
Cyanosis:absent
Pedeal edema:absent
Lymphadenopathy:absent

Vitals:
Pulse :78bpm
Rhythm: regular ,character:normal,no radiofemoral delay
Bp:110/70
Respiratory rate:19/cpm
Temperature:afebrile

CNS Examination:

Higher mental functions: conscious , oriented to time ,place and person
Memory:immediate,recent,remote-good
Concentration:good
Speech:normal
Hallucinations:absent 

Cranial nerve examination:-

CN1:- smell sense RIGHT LEFT 

                                    + + 

CN2:- visual acuity normal Normal 

CN3,4,6:- extra ocular movement : full and free in all directions. 

    Direct light reflex :-present 

    Consensual light reflex :-present 

    Ptosis :- absent 

    Accommodation reflex :-present 

CN5:- Sensory : over face ,buccal mucosa : normal 

                   Motor: masseter ,temporalis : normal 

                    Reflexes :corneal : normal

                                 Conjunctival : normal 

 CN7:- Motor : nasolabial fold : present 

            

                Reflexes: corneal conjunctival present 

 CN8:- Rinnes:- +

               Webers:- not lateralised 

             Nystagmus :- absent     

          

CN9 ,10 :- uvula movements normal 



Motor system:

BULK: Inspection : normal

             Palpation : normal

MID ARM CIRCUMFERENCE: 

Upper limb R L 

Proximal muscles. 21cm. 21cm

Distal muscles:19cm,19cm



Lower limb R L 

Proximal muscles. 35cm. 35cm

Distal muscles 26cm, 26cm                                                   

TONE:  upper limbs:- normal

           both lower limbs- normal

POWER:   
Shoulder:R L 

Abduction:5/5,5/5

Adduction:5/5,5/5

Flexion :5/5,5/5

Extension:    5/5,5/5
 
 Elbow:R L

Flexion. 5/5,5/5

Extension: 5/5,5/5



Wrist:

Flexion:5/5. 5/5

Extension: 5/5. 5/5

Abduction : 5/5. 5/5

adduction:5/5. 5/5

Hand grip:- good



HIP:-

Flexion:5/5. 5/5 


Extension. 5/5. 5/5




Knee :-

Flexion 5/5. 5/5

Extension. 5/5. 5/5 

Plantarflexion:. 5/5,5/5

Dorsiflexion. 5/5. 5/5

Toe. 5/5 5/5



Reflexes : 

SUPERFICIAL:
Abdominal: present 
Plantar: present 


 DEEP TENDON REFLEXES :

                Rt Lft 

Biceps : + 1 +1

Triceps: +1 +1

Supinator: +1 +1 

Knee jerk: +2 +2

Ankle jerk: +1 +1 

Involuntary activities





SENSORY SYSTEM : 

Posterior column:

 fine touch - normal  

  Vibration - normal 

SPINO THALAMIC : 

Pain : present 

Temperature: present 

Crude touch - normal



CEREBELLAR SIGNS : 

Finger nose test : normal 

Heel knee test : able to do

Dysdiadokinesia- absent

Gait-normal

Romberg test - negative 

MENINGEAL SIGNS 

neck stiffnesses. Absent 

Kernigs sign - absent 

Brudzinski sign -absent  

SYSTEMIC EXAMINATION : -

RESPIRATORY SYSTEM : -

Trachea Central 

NVBS 



CVS :-

S1 and s2 sounds heard

No cardiac murmurs



ABDOMINAL EXAMINATION : 

shape - scaphoid

Palpable mass - no

Liver - not palpable

Spleen - not palpable

Bowel sounds - normal
 
Provisional diagnosis : hyperglycemia with anaemia

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