A 70 YR OLD FEMALE WITH DECREASED SENSORIUM

 

70YR OLD FEMALE WITH DECREASED SENSORIUM

February 17, 2022
CBBLE UDHC SIMILAR CASES

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 patient's clinical problems with collective current best evidence based inputs.


70 YR OLD FEMALE CAME TO CASULITY WITH C/O
1)DECREASED APPETITE SINCE 5DAYS.                   2) IRRELEVANT TALK SINCE 1DAY.

HOPI

 PATIENT WAS APPARENTLY ASYMPTOMATIC 15YRS BACK, HAD H/O GIDDINESS AND DIAGNOSED AS HTN ON MEDICATION T.TELMA 20MG OD, DM-II ON T. GLICAZIDE 60MG OD SINCE THEN.

H/O DIZZINESS  2YRS BACK - CT BRAIN DONE WHICH SHOWED AGE RELATED ATROPHIC CHANGES.



STARTED MEDICATION.
REPEATED CT AFTER 1 YEAR ,WHICH SHOWED THE SAME AGE RELATED ATROPHIC CHANGES.


6 MONTHS BACK HAD H/O FALL IN A FAMILY FIGHT AND HAD SUSTAINED INJURY TO RIGHT HIP , BUT NO ABSOLUTE FRACTURE.

1MONTH BACK HAD H/O 1EPISODE OF HYPOGLYCEMIA AND PATIENTS OHA DOSE WAS REDUCED TO HALF I.E T. GLICAZIDE 60MG - 30MG.

SINCE 5DAYS DECREASED APPETITE PRESENT. 

NOT OBEYING COMMANDS SINCE 1DAY.

NO H/O FEVER, HEADACHE, NAUSEA, VOMITINGS, TRAUMA, LOC, SEIZURES, MOTOR IMPAIRMENT. 


PAST HISTORY

 KNOWN CASE OF  DIABETIS ON T.GLIDAZIDE 60MG TO 30MG FROM 1MONTH AND KNOWN CASE OF HYPERTENSION SINCE 15YRS ON TELMA 20MG.
NOT A KNOWN CASE OF CAD, ASTHMA, TB.

PERSONAL HISTORY

APPETITE - DECREASED
DIET - MIXED
SLEEP - ADEQUATE
BOWEL AND BLADDER - REGULAR

FAMILY HISTORY

INSIGNIFICANT

GENERAL EXAMINATION

NO PALLOR
NO ICTERUS
NO CYANOSIS
NO CLUBBING
NO LYMPHADENOPATHY
NO OEDEMA

VITALS

PR - 62 BPM
RR - 16 CPM
TEMPERATURE - AFEBRILE
BP - 90/60 mm/hg

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM

POSTION OF TRACHEA - CENTRAL
NO DYSPNEA
NO WHEEZE
VESICULAR BREATH SOUNDS - HEARD
BILATERAL AIR ENTRY -  PRESENT

CEREBROVASCULAR SYSTEM

HEART SOUNDS - S1, S2 HEARD
MURMURS - NOT HEARD

ABDOMEN

SHAPE OF ABDOMEN - OBESE
NO TENDERNESS
LIVER - NOT ENLARGED
SPLEEN - NOT PALPABLE

CNS 

CONFUSED
INCOHERENT SPEECH
NECK STIFFNESS PRESENT.

MOTOR SYSTEM - 
POWER - MOVING ALL LIMBS
TONE - NORMAL 
SENSORY SYSTEM - CANT BE ELICITED.

PROVISIONAL DIAGNOSIS - 

ENCEPHALOPATHY SECONDARY TO ? SEPSIS.

ECG


 X-RAY







TREATMENT - 

1. IVF- NS AND RL 100ML/HR.
 RT FEEDS 100ML MILK 4TH HRLY, 50ML 2ND HRLY WATER .
2. INJ. PIPTAZ 40MG IV/OD.
3. INJ. PANTOP 40MG IV/OD
4. INJ. ZOFER 4MG IV/SOS.
5. INJ. NEOMOL 100ML IV/SOS 
6. SYP. POTCHLOR 15ML IN GLASS OF WATER RT/ TID.
7. GRBS 6TH HRLY
           


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