Case 16 : A 60YEAR OLD FEMALE WITH ALTERED SENSORIUM

                                               MEDICINE CASE DISCUSSION

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September 13, 2022

A 60 year old woman presented yesterday to our casualty with the chief complaints of Altered sensorium since 5pm since yesterday 

Right upper limb and lower limb weakness since 5pm yesterday 

HISTORY OF PRESENTING ILLNESS-

A 60 year old woman, vegetable seller by occupation who is a mother of 2 children, residing at Arvapally was apparently asymptomatic 10 years back when she had itching of her right thigh and upon scratching she developed right lower limb edema and was treated in our hospital for 3 months - ? History of Right lower limb cellulitis 

Then she was even diagnosed to be a diabetic. 

In the month of January this year, she developed generalised weakness along with dysnpea for which she was taken to a government hospital and she was treated for URTI and was discharged after 3 days. 

Following week she started to experience dyspnea which aggravated on exertion and on supine position, PND + along with excessive sweating. 

She also experienced low grade fever along with non productive cough back then. 

She gradually developed weakness of right upper limb and lower limb as well. She was got to our hospital with these complaints and she was diagnosed to have DCMP with an EF of 25% and with Acute few hemorrhagic infarcts in her right frontal lobe. Her metabolic profile was normal. 

After a stay in our hospital for a period of 5 days, she was discharged on Tab Metformin 500mg BD, Tab Ramipril 5mg OD, Tab Lasix 40mg BD, Tab Ecosprin 75mg OD, Tab Atorvas 20mg OD along with Inj HAI ( the attendant doesn't know how much she takes).

Following which she regained power of right upper and lower limbs and continued doing  her daily activities. Yesterday while she was sitting on the chair and having a conversation with her husband she suddenly fell off from her chair and stopped responding to her attendants.

 They also noticed that she was not raising her right upper and lower limb and she would intermittently open her eyes.

She was taken to an outside hospital and an MRI was done which showed acute infarct in left MCA territory along with chronic small vessel ischaemic changes and diffuse cerebral atrophy. 

FAMILY HISTORY-

Not significant 

PERSONAL HISTORY-

Diet-mixed 

Appetite-decreased 

Bowel and bladder movements-regular and normal 

Addictions -none 

Sleep -adequate 

On examination:

VITALS-

Pallor +

PR - 85bpm

Bp - 120/70mmhg

Spo2 - 98%

Temp - 98.4 F

SYSTEMIC EXAMINATION-

Bilateral cataract+ 

GCS - E4 V2 M6

Power    Right   Left

         UL    0       3+

        LL     0       3+

Tone - Reduced in right upper and lower limb

Reflexes- 

        Right     Left

B    -         3+

T    -        3+

S    -        3+

K    -        - 

A    -         - 

P   Extensor 

No meningeal signs 

Cvs - S1,S2 heard

Lungs- BAE +,NVBS heard 

P/A-soft and non-tender 

Diagnosis - 

Acute Right MCA infarct 

Known case of DCMP 

Known case of Type 2 DM

15/9/2021

SOAP NOTES -17/9/2021

60 year old woman 

Has been shifted from amc to ICU 

Her sensorium has determined 

S-patient is in altered sensorium

Gcs  - E1V1M1

Corneal, Conjunctival reflex +

O-On examination:

Pallor +

PR - 62bpm

Bp - 120/70mmhg

Spo2 - 98%

Temp - 100 F 

Stool passed 5 days back

Bilateral cataract+ 

GCS - E4 V2 M6 

Power    Right   Left

         UL    0       3+

        LL     0       3+

Tone - 

Reduced in right upper and lower limb 

Reflexes- 

        Right     Left

B    +    3+

T    +       3+

S    +        3+

K    -        - 

A    -         - 

P   Mute 

No meningeal signs 

Cvs - S1,S2

Lungs- BAE +

Diagnosis - 

CVA with right hemiparesis secondary to ischaemic stroke with infarct in left fronto parietotemporal region  with right  capsuloganglionic region with (inv left mca territory) 

History of CVA with right frontal region hemorrhagic infarcts

k/c/o dcmp with HfREF since 6 months 

k/c/o type 2 DM since 10 years. 

Plan of care-

Head end elevation

Ryeles tube feeds-100 ml milk 2nd hourly

100 ml water 2 nd hourly

Tab.ecospirin Av (75/20) HS

Inj.HAI according to sliding scale 

Inj Lasix 20mg IV BD

Tab.pan 40mg IV OD

Syr.lactulose 10ml/BD

O2 inhalation

18/9/2021

The patient died at 8:07pm due to cardiac arrest