68 F WITH ALETRED SENSORIUM SINCE 2 DAYS

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I have 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 diagnosis and treatment plan.

 B.Pavithra(Intern)

Roll no:9

CASE:

Patient was brought to the casualty with the c/o altered sensorium since 2 days

HOPI:

Patient was apparently asymptomatic 2weeks back then she developed non bilious,non projectile vomitings 5 episodes food particles as a content associated with nausea treated with iv fluids at local hospital.loss of appetite,generalised weakness from 2days,altered sensorium worsened, intermittently gaining Orientation

No h/o fever,loose stools

No h/o constipation

H/o burning micturition

No h/o chest pain, palpitations,sob

No h/o seizures,loss of consciousness and headache.

PAST HISTORY:

K/c/o htn since 20 yrs on t.telmisartan 40mg+clinidipine+chlorothiazide 12.5mg

K/c/o dm since 20 yrs on t.glimiperide 1mg +metformin 500mg

PERSONAL HISTORY:

DIET:mixed

APETITE: decreased since 2 days

SLEEP: adequate 

B/B: regular

ADDICTIONS:none

GENERAL EXAMINATION:

Patient is drowsy, 

MMSE:

Orientation to time:1

Orientation to place:2

Registration:3

Attention:0

Recall:2

Naming:3

Repeatation:0.5

Read and follow commands:1

Sentence:0.5

Copying:0

Score:13/30

Vitals:

Temp:98.6F

PR:84bpm

RR:19 cpm

BP:120/70mm.hg

Spo2:99%

GRBS:164mg/dl

Mild pallor present,no signs of icterus,cynosis,clubbing, generalised lymphadenopathy and pedal edema 

SYSTEMIC EXAMINATION;

RS: 

BAE+ ,NVBS HEARD.

CVS:

S1 s2 heard,no murmurs

CNS:

Hmf are intact,nfnd

PROVISIONAL DIAGNOSIS: ALTERED SENSORIUM 2° TO DYSELECTROLYTEMIA.

 

INVESTIGATIONS:

ECG:

CHEST X-RAY:

2D ECHO:

USG ABDOMEN:

SEROLOGY:negative

HEMOGRAM:

SERUM ELCTROLYTES:

RFT:

Treatment:

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) ARISTOZYME PO/TID

4)Inj.HUMAN ACTRAPID INSULIN S/C TID 

5)Tab. TELMISARTAN 40MG PO/OD 

6) SYP.CREMAFFIN PLUS 15ml/PO/STAT

7) Vitals monitoring 2 hrly

8) GRBS monitoring