65 year old female with altered sensorium

65 year old female with altered sensorium

November 23, 2022

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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.

CASE PRESENTATION:

A 65 year old female, came with c/o unresponsiveness since 2 days.

History of presenting illness

Pt was apparently asymptomatic 5 days back ,then she developed fever andpain in right hip and stopped going to work for one day.then she was alright for 2 days later morning She is unable to recognize her family members properly, complaining of some one is going to attack her.

She also had an episode of involuntary urination next day morning in her sleep

H/O 90 ml alcohol intake every day since 5 years

PAST HISTORY:

Not a k/c/o DM/HTN/TB/ASHTMA/EPILEPSY/CAD 

H/O Hysterectomy 20 years ago

Personal History :

Diet : mixed

Appetite : Normal 

Sleep : Adequate 

Bowel movements : Normal 

Bladder movements : Normal

On Examination :

Patient is unresponsive 

Pallor -Absent

Icterus -Absent

Cyanosis -Absent

Clubbing -Absent

Lymphadenopathy -Absent

Edema -Absent

Vitals at presentation 

Bp-180/100mmhg measured on right hand supine position 

PR-90 bpm

Cvs- s1 s2+

RS- BAE+

CNS-

Pupils at presentation

Bilateral constricted non reactive to light

GCS At admission 

E2V1M4

Power: Couldn’t be elicited 

Moving all four limbs to pain

TONE

U/L. Normal. Normal

L/L. Normal. Normal

Reflexes: Right. Left. 

Biceps. ++. ++

Triceps. ++. ++

Supinator ++. -

Knee. ++. ++

Ankle - -

Bilateral plantars flexors 

Today's vitals

BP-140/80mmhg 

PR-67bpm

Treatment:

1.RT feed - 100ml milk 4th hrly,100 ml water 2nd hrly

2.INJ.LEVIPIL 500 MG /IV/BD

3.INJ.DEXAMETHASONE 8 MG /IV/TID

4.IVF-NS@100ML/HR

PROVISIONAL DIAGNOSIS:ALTERED SENSORIUM SECONDARY TO ? MENINGOENCEPHALITIS 

Treatment on 19/11/22

1.RT feed - 100ml milk 4th hrly,100 ml water 2nd hrly

2.INJ.LEVIPIL 500 MG /IV/BD

3.INJ.DEXAMETHASONE 8 MG /IV/TID

4.IVF-NS@100ML/HR

Treatment on 20/11/22

1.RT feed - 100ml milk 4th hrly,100 ml water 2nd hrly

2.INJ.LEVIPIL 500 MG /IV/BD

3.INJ.DEXAMETHASONE 8 MG /IV/TID

4.IVF-NS@100ML/HR

On 21/11/22

1.RT feed - 100ml milk 4th hrly,100 ml water 2nd hrly

2.INJ.DEXAMETHASONE 8 MG /IV/TID

3.IVF-NS@100ML/HR

4.TAB.RIFAMPICIN 600 MG

5.TAB.PYRAZINAMIDE 1200 MG

6.TAB.ISONIAZID 300 MG

7.TAB.ETHAMBUTOL 1100 MG RT/OD

On 22/11/22

1.RT feed - 100ml milk 4th hrly,100 ml water 2nd hrly

2.INJ.DEXAMETHASONE 8 MG /IV/TID

3.IVF-NS@100ML/HR

4.TAB.RIFAMPICIN 600 MG

5.TAB.PYRAZINAMIDE 1200 MG

6.TAB.ISONIAZID 300 MG

7.TAB.ETHAMBUTOL 1100 MG RT/

On 23/11/22

1.RT feed - 100ml milk 4th hrly,100 ml water 2nd hrly

2.INJ.DEXAMETHASONE 8 MG /IV/TID

3.IVF-NS@100ML/HR

4.TAB.RIFAMPICIN 600 MG

5.TAB.PYRAZINAMIDE 1200 MG

6.TAB.ISONIAZID 300 MG

7.TAB.ETHAMBUTOL 1100 MG RT