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
           


Comments

Post a Comment

Popular posts from this blog

A 20 YEAR OLD MALE CAME WITH FEVER AND VOMITING

Image
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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. A 20 year old male driver came to opd wit complaints of  1) Fever since 2days  2) Vomiting since 6hrs HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 2 days back then he developed fever which is not associated with chills and rigors and relieved with medication. No diurnal variation. Vomiting since 6hrs with 3 episodes and content as food material, blood tinged, non bilious, non projectile. He skipped 1 dose on insulin yesterday evening. No h/o loose stools, pain
Read more

INTERNSHIP LEARNING ASSESSMENT

INTERNSHIP LEARNING EXPERIANCE PAJRs I created around 3 PAJR  groups and updated critical data about the patient like his ECG, Chestxray, 2D-Echo, Feverchart. PAJR mainly consists of blogs and soapnotes  SOAP NOTES Soap notes consist of complaints, Vitals, Diagnosis and Treatment of patient. FEVER CHART In medicine department my pgs taught me how to plot fever chart,importance of fever chart . PERIPHERALS I learnt - To d raw samples from radial and femoral artery. - Took ABG sample - Performed CPR - Secured multiple cannula - Inserted Foley’s catheters, condom catheter and Ryle’s tube - Monitored vitals of all patients either hourly. -Attended rounds for ICU and AMC cases. NEPHROLOGY AND WARD DUTY - Assisted  how to secure a central line  -  Give IV injections - Seen the complications of dialysis - Monitored the patients undergoing dialysis -  Observed multiple CKD cases requiring dialysis. PSYCHIATRY   - I learnt alot of cases about Schizophrenia, depression, OCD, Anxiety disorders. -
Read more

A 80 YEAR OLD MALE WITH AKI WITH DIABETIC NEPHROPATHY

Image
  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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. An 80-year-old male resident of Kamanpet was admitted with complaints of  1) Acute urinary retention for past 24 hrs. 2) Fecal retention for the past 24 hours. HISTORY OF PRESENTING ILLNESS The patient was apparently asymptomatic a month ago then he began experiencing bilateral lower limb and knee pain.  Patient experienced inability to defecate (accompanied by the absence of flatus) and urinate, along with shortness of breath since yesterday .  No H/o of fever, nausea, vomiting
Read more