75 year old female with altered sensorium

Hello, I am Harshitha Shalini , a 5th semester medical student.  This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

A 75yr old female was brought to the casualty with
CHIEF COMPLAINTS:
Drowsiness and giddiness since 16/07/23 afternoon

HOPI:
patient was apparently asymptomatic till 2pm, after which she started feeling drowsy and sleepy. She took 2 tablets of ranitidine at 2pm. She is drowsy but arousable.
No h/o altered behaviour, agitation, irrelevant talk, screaming.
No h/o fever,neck stiffness
H/o toddy consumption on 15/7/23

PAST HISTORY:
No h/o similar complaints in the past
Not a k/c/o HTN , DM ,CAD,Asthma, Epilepsy,TB, Thyroid disorders
H/o cataract surgery
H/O hysterectomy

PERSONAL HISTORY:

mixed diet

Normal appetite 

Regular Bowel and Bladder movements

Sleep -adequate

No allergies 

addictions - she consumes toddy 750 ml daily in summer season and 3 times a week in the other times

She ocassionally consumes whisky

H/O tobacco chewing 

FAMILY HISTORY:
Insignificant

MENSTRUAL HISTORY:
Attained menopause 20 years back
H/O hysterectomy 5 years back

General examination:
Slightly pallor 
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No pedal oedema
Vitals:

temp-afebrile

Pulse rate -88 bpm

RR-16 cpm

BP-90/60 mm of Hg

Spo2-97

GRBS-116

SYSTEMIC EXAMINATION:

CVS

S1,S2 present

NO MURMURS

RESPIRATORY SYSTEM-

BAE+

NVBS heard

Per abdomen- soft,non tender 

CNS-

B/L pupils reacting to light

Tone in all four limbs normal

Power  -                 RT                   LT

                   U/L        4/5                  4/5

                    L/L        4/5                  4/5

REFLEXES- B     T     S     K    A   P

           Rt      ++   -       -      ++  -   -

           Lt      ++   ++   +     ++  -    -

DAILY ROUTINE -

Patient used to get up at 6:30 am and she used to sweep house and wash clothes and drink some milk and she cooks food for herself , eat by 1:00pm and take some rest. At 4:00pm she used to play pachis game with her neighbors and by 7 pm she cooks her dinner and have her dinner by 8pm and goes to bed by 10pm

Her daily routine has changed from 15/07/23

She woke up at 6:30am done her routine work and cooked food .after having food she felt some burning sensation in her chest so she took zintac tab, even after that she didn't fell well so she took 2 tablets at 2:00pm. Then she felt  drowsy and slept. her attender came to home from work at 5:00pm and they found her sleeping so they woke up her .then she had a slurred speech they waited till 6:30pm and brought her to casualty

PROVISIONAL DIAGNOSIS:

ALTERED SENSORIUM UNDER EVALUATION (RESOLVING) WITH GIDDINESS UNDER EVALUATION(?VERTIGO)

INVESTIGATIONS:

Serum creatinine 


Serum electrolytes


LFT


Blood urea


RBS


ECG


USG abdomen


Treatment-

Inj.THIAMINE 200 mg in 100 ml NS IV/OD

Vitals monitoring 

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