78 year old female with giddiness and history of fall

 This is an E log book to discuss our patient's de-identified health data after taking his guardian sign informed consent. Here we discuss our patient's problem through series of inputs from available global online community of experts with an aim to solve those patient's clinical problem with collective current best evidence based inputs. This E log book also reflect my  patient centered online portfolio and your valuable inputs on comment box.


This is a case of 78 year old female who was brought to hospital with history of giddiness since 3 days.

She had history of fall 3 days ago following an injury in left hand.

She was unable to walk since 1 day.

She was having drowsiness and vomitings since morning.


HISTORY OF PRESENT ILLNESS

She was apparently normal 8 days back when she had giddiness and fall, following which she sustained injury to left hand where she developed swelling, blebs and had difficulty in walking.

She had complaint of vomitings 2 episode with food as content.

She was given ceftriaxone for 3 days by local RMP.


PAST HISTORY

She had history of admission in hospital in February with complaints of vomitings, altered sensorium no clear history about treatment is known.

History of diabetes mellitus since 10-15 years.

History of hypertension since 10 years.

Not a known case of asthma, TB, epilepsy and CAD.


TREATMENT HISTORY

She was on unknown treatment for diabetes mellitus and hypertension.


PERSONAL HISTORY

Diet: mixed 

Bowel and bladder: regular

Appetite: normal

Sleep: adequate

Addictions: nil 


FAMILY HISTORY

Not significant


EXAMINATION

Patient was drowsy, oriented to time and place. No pallor, cyanosis, icterus, lymphadenopathy.

Temperature: 98.6 F 

BP- 130/90 mmHg 

Pr- 85bpm

RR-18cpm 

Spo2-98% ai room air 

GRBS-104 mg/dl 


SYSTEMIC EXAMINATION

CVS- S1 S2 +

R/S- bae+, NVBS 

P/A- distended abdomen,non tender 

CNS- drowsy, oriented to time, place and person.

                       RT.           LT

Biceps:.        2+.            2+

Triceps        2+.            2+

Supinator   1+.            1+

Knee            1+.            1+

Ankle 

Plantar- withdrawal in both limbs.



















DIAGNOSIS

LEFT UPPER LIMB CELLULITIS 

ALTERED SENSORIUM SECONDARY TO UREMIC ENCEPHALOPATHY.


TREATMENT

INJ PIPTAZ -2.25 gm IV/ tid 

INJ Metrogyl -100 ml IV/tid 

INJ Zofer -4 mg IV/sos 

IVF NS,RL @100ml/hr 

Tab Shelcal po/rt/of 

INJ Optineuron 1 amp+100ml NS/IV/OD

















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