A case of a 65 year old female with Altered sensorium

 November 25, 2022

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current based inputs.

A case of a 65 yr old female with altered sensorium.

patient is  65 year old  female housewife hailing from a rural district in south india

Patient was brought to casuality on 23/11/22 at 4:00 am early in the morning with complaints of loose stools since 5 days and pain as mentioned by the atttender as she was screaming and restless with altered sensorium.

History of presenting illness:The patient was apparently asymptomatic 5 days ago. She passed loose stools- watery in consistency, foul smelling and blood tinged on consuming kaya churnam (an ayurvedic powder) , went to RMP nearby and was given medication,  even upon which loose stools didnot stop . The attender mentions she became weak and then on 23rd nov, apparently after eating curd rice ,  when patient slept , suddenly in the middle of night patient was screaming due to pain  and could not talk anything, as mentioned by the attender. She was then bought to casuality.

History of past illness:The patient's attender also tells  that few yrs back in 2009,  she fell down in bathroom and became unconscious . She was unconscious for 10 to 15 days and during that period couldnt recognize anyone and couldnt talk and later when she was conscious, she could recognize their family members and diagnostic as hypertensive. But since then, she restricted herself to bed and didnt walk much due to fear of falling down and didnt do much work. She is going for regular checkups  once in every 3 months for BP, and weakness.N/k/c/o Diabetes, TB or asthma., CAD, epilepsy 

Addictions: . None

Family history : His husband was a diabetic who passed away in 2008 and 1 st son is diabetic too.

Surgical history: Hysterictomised 50 yrs ago

Treatment history : Telmisartan, vit D3 , Ca2+

Personal history : 

Daily routine : Patient would wake up at 6am and would have chai , biscuits , take a bath by walking with help of a walker and then have her breakfast at 8 am and would then relax , talking to her daughter in laws and would have her lunch and  the attender mentioned she would have a lot of water of about 4 litres per day and sleep in the afternoon and in the evening she would talk to her grandkids and have curd rice for dinner by herself and would sleep by 10. Since 2 yrs she has not been sleeping properly and would manage only 2 - 3 hrs sleep in night. Since 5 - 6 days she is eating sabhudhana, curd rice only

Diet: mixed

Appetite : decreased

Sleep : inadequate

Bowel movements : increased since 5 days

General examination: patient was examined after taking consent from the attenders.

Pt in not cooperative and coherent qnd ia irritable.

Pallor  - present

Icterus- absent

Cyanosis- absent

Clubbing- absent

Koilonychia - absent

Lymphadenopathy - absent

Edema - grade 1 pedal edema

Vitals at presentation 

bp-100/80mm Hg

PR-104 bpm

Respiratory rate : 17/min

SpO2 : 96%

Temperature : Afebrile

Systemic examination :

CVS :

No thrills, no parasternal heave, 

S1, S2 +, no murmurs

Respiratory system :

Trachea is central in position, no dyspnoea, no wheeze,  vesicular breath sounds heard

Abdomen examination :

 Non tender , bowel sounds heard

CNS :

Oriented to person but not to time and place.

Repeatation : absent

 Recall: absent

Language : absent

GCS : E4 V4M6

TONE :  Rt               Lft

U/L.      Normal.  Normal

L/L.      Normal.     Normal

Power : 

U/L        3/5               3/5

L/L         3/5               3/5

Reflexes: 

                   Right.     Left. 

Biceps.      ++.        ++

Tricep.   ++.       ++

 Speech - normal

 Signs of meningeal irritation - not present

Investigations

Serum electrolytes on 23 rd novSerum electrolytes on 24 nov 202Hemogram on 23 nov 2022Hemogram on 24 nov 202ABGFEVER CHARTX RAY:

Provisional diagnosis :AlteredsensoriumsecondarytHyponatremia (Hypovolemic Hyponatremia)(True Hyponatremia) secondary to GI loss? Dysentery with Anemia under Evaluation.

Treatment 1.INJ. NS @ 75 ml/hr

2.INJ. METRONIDAZOLE 500 MG /IV/TID

3.INJ. PAN 40 MG /IV/OD

4.IVF-ZOFER 4mg /IV/SOC

5. ORS sachet 1 in 1 litre of H20 . Drink after each episode of loose stools

6. TAB SPOROLAC  - DS / FO/TID

7. Ryles tube insertion

8.  INJ. Metrogyl 100ml/iv/TID

9. Head end elevation

10 . INJ. Monocef 1gm/IV/TID 

11.Change posture 2 hourly.

12.SYP POTCHLOR 15ML in 1glass of water.