case 12 : 60F with Altered sensorium
thanks sai raghu (intern)
CASE WITH ALTERED SENSORIUM PRESENTED IN SUMMER 2021
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DRUG HISTORY
➤No significant drug history.
PERSONAL HISTORY
➤Patient takes mixed diet but has a decreased appetite.
➤Bowel and bladder movement is normal and regular.
➤Self care and hygiene not maintained
➤Alcohol consumption 10 years occasionally once in a month (180ml whiskey)
But stopped alcohol intake 6 months back.
➤H/O of consumption of tobacco leaves for the past 5 years (2-3 leaves per day)
FAMILY HISTORY
➤No family history of psychiatric illness.
ALLERGIC HISTORY
➤No significant allergic history
GENERAL EXAMINATION
➤Pallor : Not seen
➤Icterus : Not seen
➤Cyanosis : Not seen
➤Clubbing : Not seen
➤Lymphadenopathy : Not seen
➤Edema : Not seen
➤Malnutrition : Not seen
➤Dehydration: Present
VITALS
➤Temperature : 98.4℉
➤PR : 84 beats per minute
➤BP : 130/70 mmHg
➤RR : 18 cycles per minute
➤SpO2 : 99% in room air
➤Blood Sugar (random) : 186 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
ABDOMINAL EXAMINATION
➤Abdomen is soft
➤Non tender
➤No palpable mass
➤Bowel sounds are heard
CENTRAL NERVOUS SYSTEM
Intellectual functions
-patient is conscious,oriented to time ,place and person
-memory-immediate,recent and remote memory present
-appearence-well kept
-speech-normal
2)cranial nerves
Olfactory-smell present on both sides
Optic-visual acuity -6/6
Visual field,colour vision,reflexes -normal
3,4,6 cranial nerves-ocular movements -present
Nystagmus,pros is,Diplopoda-absent
Pupils are normal
Trigeminal -motor and sensory functions normal on both sides
Facial nerve
-No deviation of mouth
-frowning present
-absent nasolabial folds on left side
-blowing and whistling absent
Taste sensation on anterior 2/3rd of tongue present
Corneal reflexpresent on both sides
Vestibulocochlear nerve-rinnes Weber,schwabach test Negative on both sides
Vagus and glossopharyngeal -uvula midline
Spinal accessory-shrugging of shoulders present
Hypoglossal-no deviation of tongue
3)Motor system
A)attitude and position-Normal
B)bulk-no wasting
C)tone-Rt Lt
UL N N
LL N N
D)power-
UL Rt Lt
-5/5 -5/5
LL -5/5 4/5
4)Reflexes
Superficial Rt Lt
Corneal +2 +2
Conjunctival +2 +2
Abdominal +2 +2
Deep Rt Lt
Biceps +2 +3
Triceps +2 +2
Supinator +2 +2
Knee +2 +2
Ankle +2 +2
5)Sensory system
Superficial -fine touch,temperature,pain -present
Deep-position,vibration,crude touch,stereognosis,2point discrimination- present
6)Cerebellum
Speech,nystagmus,ataxia,tremors,released reflexes absent
7)Coordination and gait
Finger nose test ,finger finger test,heel knee test-present
Gait -Normal type
Romberg test -negative
8)signs of meningeal irritation
Nuchal rigidity,kernigs and brudzinski’s sign - absent
PROVISIONAL DIAGNOSIS : ALTERED SENSORIUM SECONDARY TO HYPONATREMIA SECONDARY TO VOMITING
INVESTIGATIONS :
DAY 1
 |
| NORMAL |
 |
| MILDLY ELEVATED |
 |
| HYPONATREMIA-130mEq/L |
 |
| NORMAL |
 |
| NORMAL |
 |
| DECREASED LEVEL OF PROTEIN - 5.1g/dl |
 |
| SERUM BILIRUBIN IS MILDLY ELEVATED |
 |
| SGPT IS NORMAL |
 |
| S.CREATININE IS NORMAL |
 |
| HB is decreased10.6g/dl TOTAL COUNT IS ELEVATED-12,900cells/cumm |
DAY 3
 |
| CHEST X-RAY AP VIEW |
DAY 1
➤Patient was referred to psychiatry department for cross consultation.
➤Patient was not cooperative
➤Na- 130 mEq/L
➤Potassium - 3.6 mEq/L
➤Chloride-97mEq/L
➤Hb-10.6g/dl
➤WBC- 12900 cells/cumm
1) TAB.CLONAZEPAM 0.5mg BD
DAY 2
➤C/O headache
➤Fever spikes absent
➤PR-98 beats/min
➤BP-130/80mm of Hg
➤GRBS-135mg/dl
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) INJ.ZOFER 4mg IV/TD
4) ORS sachets 2 in 1 litre
5) BP/PR/TEMP./SpO2 montoring
DAY 3
➤C/O headache
➤Fever spikes absent
➤Patient is conscious and irritable
➤PR-78 bpm
➤BP-160/100 mm of Hg
➤Patient was referred to ophthalmology department for cross consultation
 |
| No view of fundus in both eyes due to dense cataract |
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) INJ.ZOFER 4mg IV/TD
4) ORS sachets 2 in 1 litre
5) BP/PR/TEMP./SpO2 montoring
DAY 4
➤Headache decreases
➤Fever spikes absent
➤Stools passed
➤Patient is conscious ,coherent and cooperative.
➤PR-86 bpm
➤BP-130/80 mm of Hg
➤GRBS-211 mg/dl
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) IV fluids NS @ 100 ml/hour
4) TAB.PCM 650mg TID
5) INJ.ZOFER 4mg IV/TD
6) ORS sachets 2 in 1 litre
7) BP/PR/TEMP./SpO2 montoring
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