A 74 year old male patient came to the opd with the chief complains of giddiness.

                  E LOG GENERAL MEDICINE.

Hi, I am Anvitha, 6th 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.

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•  * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

                                   CASE SHEET.                                           

Chief complaints and duration.

A 74 year old male patient came to opd with the chief complain of giddiness and weakness for five hours on Thursday afternoon.

History of present illness.

Patient was apparently Asymptomatic till Thursday afternoon then he developed headache which relieved on medication then that evening he was unable to get up from the toilet. Started developing profuse sweating with generalised weakness which decreased on medication from a local doctor later that evening. Since then he was having headache and giddiness. 

History of past illness.

In 1987 he had a major accident where his right knee and hip was fractured for which a rod was placed by operation.

K/C/O HTN and DM since 15 years.  Patient had a burn on his right leg which was not relieved on self medication so he we t to the hospital. On investigations he was diagnosed with HTN and  DM. 

Joint pains since  5 years

Personal history.

Patient is a retired RTC  worker by occupation.   

  Bowel movement is regular.

Micturition is normal.

No history of Allergy.    

No addictions.

Family history

 Mother was a known case of HTN and DM.

PHYSICAL EXAMINATION.

A. General Examination 

No Pallor

No icterus

No cyanosis

No clubbing of fingers

No lymphadenopathy

No malnutrition 

No clubbing of fingers

No dehydration

Bilateral pedal Oedema is present 

Temperature: 98.6 F

Pulse: 88/ min

Blood pressure: 110/70c