70YR OLD FEMALE WITH DECREASED SENSORIUM

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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 DECREASED APPETITE SINCE 5DAYS.
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 H/O: K/C/O DIABETIC  ON T.GLIDAZIDE 60MG TO 30MG FROM 1MONTH AND K/C/O HYPERTENSION SINCE 15YRS ON TELMA 20MG.
N/K/C/O CAD, ASTHMA, TB.
O/E:
PR: 62BPM, RR: 16CPM, BP: 90/60 MMHG.
NO  PALLOR/ ICTERUS/ CYANOSIS/ CLUBBING. 
CNS: CONFUSED, INCOHERENT SPEECH
NECK STIFFNESS PRESENT.
MOTOR SYSTEM: POWER - MOVING ALL LIMBS, TONE: NORMAL 
SENSORY SYSTEM: CANT BE ELICITED. 
GCS: E4V2M6.
CVS: S1 S2 +
RS: BAE+
P/A:  OBESE ABDOMEN
PROVISIONAL DIAGNOSIS: ENCEPHALOPATHY SECONDARY TO ? SEPSIS.





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/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
           Psychiatry referal:
        Ortho referal:


Gait:  https://youtu.be/L2pOhMQsMQg
ICU BED-5
S-
Drowsy but arousable
O/e:
Pr: 78bpm, rr: 20cpm, bp: 120/80mmhg.
No  pallor/ icterus/ cyanosis/ clubbing. 
Cns: oriented to t/p/p. 
confused, incoherent speech
motor system: power - moving all limbs, tone: normal 
Cvs: s1 s2 +
Rs: bae+
p/a:  obese abdomen

A- Delirium secondary to sepsis ? Metabolic with h/o htn, dm -II + Acute transient psychotic disorder. 

P-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/od
4. inj. zofer 4mg  iv/sos.
5. inj. neomol 100ml iv/sos 
6. Tab. Risperidone 2mg 8pm 
7. Tab. Clonazepam 0.5mg (8pm). 
8. grbs 6th hrly

AMC BED 5 
DAY-5 OF ADMISSION:
S-
Generalized body pains
O/e:
Pr: 102bpm, rr: 20cpm, bp: 190/90mmhg.
No  pallor/ icterus/ cyanosis/ clubbing. 
Cns: oriented to t/p/p. 
incoherent speech
motor system: power - moving all limbs, tone: normal 
Cvs: s1 s2 +
Rs: bae+
p/a:  obese abdomen

A- Unexplained sepsis with transient psychosis due to organic brain syndrome recovered? 

P-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/od
4. inj. zofer 4mg  iv/sos.
5. inj. neomol 100ml iv/sos 
6. Tab. Risperidone 2mg 8pm 
7. Tab. Clonazepam 0.5mg
(8pm). 
8. Tab. Amlong 5mg od.
8. grbs 6th hrly


Ward case
DAY-7 OF ADMISSION:
S-
Generalized body pains decreased
O/e:
Pr: 90bpm, rr: 20cpm, bp: 120/60mmhg.
Spo2: 97%
No  pallor/ icterus/ cyanosis/ clubbing.
Cns: oriented to t/p/p.
speech- normal
motor system: power - moving all limbs, tone: normal
Cvs: s1 s2 +
Rs: bae+
p/a:  obese abdomen
GRBS: 96mg/dl 8am -> 188mg/dl 2pm -> 75mg/dl 8am
A- Unexplained sepsis with transient psychosis due to organic brain syndrome recovered? With HTN and Dm 2 since 15yrs.

P-rx:
Tab. pantop 40mg iv/od
Tab. PCM 500MG po/ sos
Tab. Risperidone 2mg 8pm
Tab. Ultracet 1/2 tab pi/qid.
Tab. Clonazepam 0.25mg
(8pm).
Tab.Cinod 10mg od.
grbs 6th hrly

Discharge summary:

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