Case 15 - A 67 year old female with altered sensorium

A 67 yr old female is a hand embroidery worker by profession until 20 years ago,she is not working since 20 years and is a housewife thereafter.She  developed sudden giddiness and seizures 15 years ago for the first time which lasted for 2-3 mins and then she became normal, when she was taken  to hospital she was prescribed some medications and used to have episodes of seizures on and off lasting for 2-5 mins once in a few months. 

6 months ago , she had a seizure in the morning immediately on waking up and had froth from the mouth she was then taken to hospital and got better after 2 days after which she was discharged.

She was prescribed medications but she was taking them irregularly

Then on 7th of this month at around 2 pm, she developed altered sensorium sudden in onset and was brought to the casuality and she was unconscious then

Her mri report from  6 months ago shows

Multiple calcified granulomas ( largest measuring 1.0X0.8 cm in the frontal lobe ) 

Chronic laccunar infarcts in pons -on Left side ,B/L basal ganglia 

Small vessels ischaemic changes 

Patient doesn't have a history of HTN , DM, CAD 

Personal history:

Her Appetite is normal,sleep adequate,is a vegetarian and has regular bowel and bladder movements ,no addictions

Family history: NAD 

Physical examination: 

PICCLE : - ve 

Temp ; afebrile 

PR: 98bpm 

RR: 22

BP :140/90 mmhg 

Spo2 : 98 

GRBS :209 mg%


Systemic examination: 

CVS : s1 s2 +

Respiratory: BAE+,NVBS 

Abdomen : soft , non tender 

CNS : unconscious 

Speech : aphasic 

No signs of meningeal irritation 

Tone : 

Right U/L: decreased , L/L- normal 

Left U/L: normal , L/L- normal 

Power : 1/5 both limbs both sides

GCS: E1V1M1

Reflexes : knee , ankle - absent 

Investigations :

8/9/21

Lft :

Total bilirubin 0.74 mg/dl

Direct bilirubin 0.20 mg/dl

SGOT : 41 IU/l

SGOT : 18 IU/l

Alkaline phosphatase : 174 IU/l

Total proteins : 7.3 gm/dl

Albumin: 4.2 gm/dl

A/G ratio : 1.35


Mri brain plain :
Serum creatinine :
Serum creatinine 1mg /dl


Blood urea :
19mg/dl

Serum electrolytes :

Sodium 141 mEq/l
Potassium 4.8 mEq/l
Chloride 92 mEq/l

Ecg :


2d echo done on 9/09/21

Fundoscopy :

Lumbar puncture was done.

Csf analysis :

Sugar 82mg/dl
Protein 31 mg/dl
Chloride 110 mmol/l

Csf cytology :

Total count : 78 cells
Differential count :  80 % neutrophils 20 % lymphocytes
Volume : 2ml
Colour : colourless

Ecg on 10/09/21




Provisional diagnosis: 

Altered sensorium secondary to cva

K/c/o epilepsy

Treatment :

Day 1

1.Ivf NS @ 50ml/hr

2.ryle's tube feeding

200ml milk 2nd hourly

100ml water hourly

3.inj.pantop 40mg iv/od

4.inj optineuron 1amp in 100ml ns/iv/od

5.inj monocef 1ug /iv/bd

6.bp,pr,spo2 monitoring every 4th hourly

Day 2

1.Ivf NS @ 50ml/hr

2.ryle's tube feeding

200ml milk 2nd hourly

100ml water hourly

3.inj.pantop 40mg iv/od

4.inj optineuron 1amp in 100ml ns/iv/od

5.inj monocef 1ug /iv/bd

6.inj phenytoin 100mg/iv/tid

7.bp,pr,spo2 monitoring every 4th hourly

Day 3 

1.Ivf NS @ 50ml/hr

2.ryle's tube feeding

200ml milk 2nd hourly

100ml water hourly

3.inj.pantop 40mg iv/od

4.inj optineuron 1amp in 100ml ns/iv/od

5.inj monocef 1ug /iv/bd

6.inj phenytoin 100mg/iv/tid

7. Inj valproate 500mg/iv/bd

8.bp,pr,spo2 monitoring every 4th hourly

Day 4 :

1.Ivf NS @ 50ml/hr

2.ryle's tube feeding

200ml milk 2nd hourly

100ml water hourly

3.inj.pantop 40mg iv/od

4.inj optineuron 1amp in 100ml ns/iv/od

5.inj monocef 1ug /iv/bd

6.inj phenytoin 100mg/iv/tid

7. Inj valproate 500mg/iv/bd

8.tab.met - xc 25mg rt/od

9.tab pcm 650mg tid

10. Inj vancomycin 1gm /iv/bd

11. Inj dexamethasone 8mg /iv/tid

12.bp,pr,spo2 monitoring every 4th hourly

13.grbs charting 8th hourly

14. Head end elevation

15. Strict I/O charting

Day 5

1.Ivf NS @ 50ml/hr

2.ryle's tube feeding

200ml milk 2nd hourly

100ml water hourly

3.inj.pantop 40mg iv/od

4.inj optineuron 1amp in 100ml ns/iv/od

5.inj monocef 1ug /iv/bd

6.inj phenytoin 100mg/iv/tid

7. Inj valproate 500mg/iv/bd

8.tab.met - xc 25mg rt/od

9.tab pcm 650mg tid

10. Inj vancomycin 1gm /iv/bd

11. Inj dexamethasone 8mg /iv/tid

12.bp,pr,spo2 monitoring every 4th hourly

13.grbs charting 8th hourly

14. Head end elevation

15. Strict I/O charting

Day 6 

1.Ivf NS @ 50ml/hr

2.ryle's tube feeding

200ml milk 2nd hourly

100ml water hourly

3.inj.pantop 40mg iv/od

4.inj optineuron 1amp in 100ml ns/iv/od

5.inj monocef 1ug /iv/bd

6.inj phenytoin 100mg/iv/tid

7. Inj valproate 500mg/iv/bd

8.tab.met - xc 25mg rt/od

9.tab pcm 650mg tid

10. Inj vancomycin 1gm /iv/bd

11. Inj dexamethasone 8mg /iv/tid

12.bp,pr,spo2 monitoring every 4th hourly

13.grbs charting 8th hourly

14. Head end elevation

15. Strict I/O charting

Day 7 

1.Ivf NS @ 50ml/hr

2.ryle's tube feeding

200ml milk 2nd hourly

100ml water hourly

3.inj.pantop 40mg iv/od

4.inj optineuron 1amp in 100ml ns/iv/od

5.inj monocef 1ug /iv/bd

6.inj phenytoin 100mg/iv/tid

7. Inj valproate 500mg/iv/bd

8.tab.met - xl 25mg rt/od

9.tab pcm 650mg tid

10. Inj vancomycin 1gm /iv/bd

11. Inj dexamethasone 8mg /iv/tid

12.inj clexane 40mg sc/od

13. Inj acyclovir 500mg iv/bd

14.bp,pr,spo2 monitoring every 4th hourly

15.grbs charting 8th hourly

16. Head end elevation

17. Strict I/O charting

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