A 55 years old female presented with the yellowish discolouration of sclera amd a semiconscious state

July 18 , 2022

E LOG GENERAL MEDICINE 

Hi, I am G. Akshara , 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.

 * This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.

Chief complaints : 

A 55 year old female patient who was previously a agricultural labourer by profession came to the opd with the chief complaint of high fever associated with chills and voice drop in a semi conscious state.

 History of present illness : 

Patient was asymptomatic 20 days back, and suddenly developed fever with burning micturition associated with yellowish discolouration of tongue, sclera and skin. 

She came to our hospital for the same and was advised admission but attendants didn’t want to get admitted.

She was prescribed medicines and went back home 

She started using herbal medicines every Monday, skipping anti hypertensive and anti diabetic medication for 3 days

On 17th night, she was normal, slept after dinner, woke up at 2 am for urination but couldn’t pass urine. She went back to sleep and woke up at 5 am when she started developing sweating, weakness and voice drop. 

She presented to the hospital in  a semi conscious state

History of past illness : 

Diabetic since 5 years.

Hypertension since 5 years.

No TB

No CAD

No Syphilis

No Asthma

Family history : 

No significant family history 

Allergies : 

No allergies

Drug history : 

Medicines for hypertension and Diabetes 

Personal history : 

Patient was previously a farmer by occupation.    

Appetite is normal

Mixed diet

Bowel movement is regular.

Bladder movement is regular.

Sleep was adequate.

Smoking  stopped 6 years back because of diabetes.

Occasionally drinking.

She underwent hysterectomy 20 years back.

PHYSICAL EXAMINATION : 

A. General Examination  

Semi Conscious , coherent and cooperative 

Well built

Pallor is absent.

Icterus is present

No cyanosis

No clubbing of fingers

No lymphadenopathy

Vitals : 

Temperature: 96.6 F

Pulse: 92

Respiration: 22/min

Blood pressure: 110/70 mmhg  

Spo2: 90%