case 34 : 70 yr old female with altered sensorium under evaluation

 

70 yr old female with altered sensorium under evaluation

- April 18, 2022
  1. thanks Dr. warsha 

    Icu bed no 3 : 
  2. 70y old female shopkeeper by occupation came to tha casuality with complaints of fever since 2 days insidious in onset gradually progressive subsided on taking medication, not associated with chills and rigour. patient attenders have observed irrelevant talk since yesterday mrng she was taken to a local hospital where she was referred to our hsptl for further management

  3.  k/c/o HTN on telma 40 and DM on glimi M2 and antiplatelets


    PAST HISTORY:

    H/o similar episodes in the past 15 years back where she was admitted in guntur hospital for 15 days and an mri scan was done which revelaed ?lnfarct  in brain 


    O/E:

    Pt is consious , non coherent , non cooperative 

    Febrile :100.8

    Bp :150/60

    PR:79bpm

    Grbs:158

    Sleep : good

    Appetite : decreased

    Bladder:irregular

    Bowel:irregular

    Alcoholic and tobacco chewer since when she is 16 yr old 

    Stopped toddy 10 years back 


    CNS EXAMINATION:

    Slurred speech 

    Pupils dilated :Rt -2-3mm

                              Lt -2-3 mm 

    Tone :          Rt                   Lt

              UL      Normal       Normal

              LL       Normal       Normal


    Power:          Rt                   Lt

             UL      5/5                 5/5

             LL       5/5                 5/5


    Relfex:    

                         Rt                  Lt

                B -   2+                 2+

                T -   2+                 2+

                S-    2+                 2+

                A -    -                   -

                K -    -                   -

                

    P-    Flexor          Flexor 


    neck stiffness +

    Kernings +

    Brudzinskis  +


    LP DONE

    V -1.5 cc

    C -colourless

    A-clear

    TC-2 cells

    DC-100% lymphocytes 

    RBC- nil

    Others-nil

    DIAGNOSIS:

          Altered sensorium under evaluation 

    ?atypical pneumonia


    INVESTIGATIONS:

    18/4/22

    Blood urea :78mg /dl

    Hb:5.7

    Tlc:7600  N/L/E/M/B:83/11/01/05/00

    Rbc:2.65 million/cumm

    Pt:2.5lk/cumm

    Impression : microcytic hypochromic anemia

    Serum creatinine:1.4mg/dl

    Serum electrolytes:

    Na:140

    K:4.8

    Cl:99

    Mg:2.1mg /dl

    Urine for ketone bodies:negative

    Abg:

    Ph :7.45

    Pco2:24.6

    Po2:90.7

    Hco3:16.9

    Blood for MP STRIP TEST :negative 

    Fbs: 450 mg/dl


    19/4/22

    Hb:7.5 

    Tlc :4600 N/L/E/M/B:75/15/04/06/00

    Rbc:3.29 million /cumm

    Pt:2.32 lk/cumm










 
X ray findings: right lower lobe pneumonia 










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