male patient having hiccups and generalized weakness(case 3)

28th November 2022

General medicine blog:

Hi , I Ebrahim Badshah , a 3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

The patient’s consent was taken prior to history taking and examination of his condition.

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. 


CHIEF COMPLAINT:
A 54 year old male came to opd with hiccups since 4 days and decreased appetite and generalised weakness since 4 days.
Similar complaints observed 8 months ago , 4 months ago and 1 month ago 

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 7 years ago . Patient is known case of diabetes and hypertension .
H/o of trauma to foot long ago .
Head injury 7 months ago .

PAST HISTORY : 
Diabetes mellitus diagnosed 7 years ago.
N/k/c/o asthma , epilepsy , cad , cvd

PERSONAL HISTORY :
No addictions
Mixed diet 
adequate sleep
Regular bowel movements
Normal appetite 

PHYSICAL EXAMINATION:
Patient is conscious and coherent
Delayed response 
Moderately built and nourished 
No icterus
No clubbing 
No pedal oedema 
No lymphadenopathy 
Malnourished/thin 
No cyanosis

VITALS:
Temperature:98°C
BP:140/80 mm Hg
HR:82/min
RR:20/min

FAMILY HISTORY:
 None

ALLERGY HISTORY:
None

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