A 70 yr old female with Altered sensorium
A 70 year old female patient who used to be a farmer by occupation and a resident of haaliya in nalgonda.
CHIEF COMPLAINTS -
A 70 old Patient was brought to casualty with chief complaints of decreased appetite since 7 days and irrelevant talk since 3 day.
HISTORY OF PRESENT ILLNESS -
Patient was apparently asymptomatic 15 years back and had a history of giddiness and was diagnosed as HYPERTENSION and DIABETES and since then she is on medication, which temporarily relieved her from giddiness.
Two years back she again started suffering from giddiness which was associated with neck pain and so she was taken to hospital, where CT Brain was taken which showed age related atrophic changes. The required medication was started since then and continued for one year and after one year again CT brain was repeated, Which showed the same age related atrophic changes.
6 months back she had a history of fall in a family fight and had sustained an injury to right hip which is causing pain till today but no absolute fracture occurred at that time.
1 month back she had a history of one episode of hypoglycemia, so her OHA(oral hypoglycemic agents) dose was reduced to half.
Since 7 days decreased appetite is present and she is not obeying commands and is not able to recognise her family members since 3 days.
No history of fever, headache, nausea, vomiting, trauma, seizures and motor impairment.
PAST HISTORY -
known case of HYPERTENSION since 15 years, who is on T.Telma 20mg
Known case of DIABETES, who is on T.Gliclazide 30mg and since 1 month
Not a known case of CAD/Thyroid/tuberculosis/epilepsy/asthma
FAMILY HISTORY -
No relevant family history
No known cases of diabetes/hypertension/ tuberculosis/asthma/epilepsy/thyroid
PERSONAL HISTORY -
Appetite is decreased
Mixed diet
Sleep is not adequate
Bowel and bladder movements are irregular
No known allergies
Patient doesn't consume alcohol
PHYSICAL EXAMINATION -
GENERAL -
Patient is conscious, incoherent and uncooperative
Patient is not well oriented to time and place
Moderately built and moderately nourished
Pallor:absent
Icterus: absent
Clubbing:absent
Cyanosis:absent
Lymphadenopathy: absent
Edema: absent
VITALS -
Temperature: afebrile
Pulse: 62 bpm
Respiratory rate: 16 cpm
Blood pressure: 90/60
SpO2 at room air: 96%
SYSTEMIC EXAMINATION -
Cardiovascular system -
s1 and s2 heard ,no murmurs
Respiratory system -
Central position of trachea
Vesicular breath sounds
No wheeze,no dyspnea
Abdomen -
Bowel sounds present
Normal shape
No tenderness
No palpable masses
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
INVESTIGATIONS -
MRI -
RX -
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/O
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. .D...
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