case 12 : 60F with Altered sensorium

 

thanks sai raghu (intern)


August 20, 2021

 

CASE WITH ALTERED SENSORIUM PRESENTED IN SUMMER 2021

August 19, 2021

 

NOTE:

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.
  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
  • This E-log also reflects my patient's centered online learning portfolio.
  • 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 a diagnosis and providing treatment best to our skills and wisdom.


A 60 years old female presented in the casualty with complaints of vomiting and altered sensorium.

CHIEF COMPLAINTs

➤10 episodes of vomiting
➤Generalised weakness
➤Drowsiness
➤Body pain

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 days ago after which she developed high grade fever 1 episode and was taken to a local doctor and was treated for the same (medical records not available). Fever subsided yesterday night.

After dinner she had 10 episodes of vomiting and patient had disturbed sleep and generalized weakness and patient was brought to casualty and admitted in the morning.

HISTORY OF PAST ILLNESS 

➤Not a known case of hypertension,diabetes,bronchial asthma,epilepsy and TB
➤No H/O of similar complaints in the past.

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


TREATMENT

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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