75 F with Altered sensorium since 1 day

 A 75 yr old female came to opd with altered sensorium since yesterday .

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G preethi reddy .

Roll no 43 

2k19

  

History of present illness:-

Patient was apparently normal until 3pm

yesterday (19/10/2023).

She then became altered since 3pm

yesterday and started speaking random words, not answering revelantly and without deviation of mouth with weakness of right upper limb and right lower limb.

Associated with involuntary micturition and slurring of speech

No C/O loss of consciousness, seizures, headache, involuntary defecation, vomitings, fever, trauma, diplopia.

History of past illness:-

H/o CVA with right sided hemiparesis 3 years back, recovered now

K/C/O Hypertension since 4 years ( not using medication regularly in past few days)

N/K/C/O DM,TB, Epilepsy,CAD, Thyroid disorders, Bronchial asthma

Personal history:-

Diet - Mixed

Appetite - Normal

Bowel and bladder - regular

Sleep - adequate

No addictions

No H/o food and drug allergies

Family history:-

Not significant

General examination: -

Patient Patient is conscious, coherent, cooperative, moderately built and nourished

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy

VITALS 

Temp- 97.8F

BP-150/90 mmHg

PR- 68 bpm

RR - 18com

Sp02-97%

Systemic examination:

CVS- S1;52 + , no murmors

RS- BAE+ NVBS heard

P/A- Soft non tender, no organomegaly

CNS :-

Patient is arousable

No signs of meningeal irritation

Tone:

Right.                         Left 

UL   Increased.         Increased 

LL Increased.            Increased 

Power:

Right.             Left 

UL. 2/5.          3/5

LL.  2/5.          3/5 

Reflexes.    Rt.     Lt 

-Biceps.      3+.     3+

Triceps.      3+.      3+

Supinator   2+.       2+

Knee.          3+.      3+

Plantar.  extension  extension

INVESTIGATIONS 

  

    

     

    

 

  

   

   PROVISIONAL DIAGNOSIS 

    Recurrent CVA asso with right side Hemiparesis with Hemorrhagic infarct in Left fronto parietal region 

  

    TREATMENT 

    19/10/2023 

     1) RT feeds - 100 ml H20 2 hrly

                            200 ml milk 4 hrly 

      2) IV fluids NS @30 ml / hr 

     3)inj mannitol 100ml IV /TID ( 8am , 2pm, 8pm ) 

     4)inj levipil 500mg IV/BID ( 8am ,8pm ) 

     5) vitals monitoring houlrly 

     6) inform SOS 

   

   20/10/2023 

  1) RT feeds 100 ml water 2 hrly 

                      200ml milk 4 hourly 

  2)IVF NS @50ml/hr

  3)Inj Mannitol 100ml IV /TID

  4)inj levipil 500mg iv/bid

  5)inj pantop 40mg IV

21/10/2023

 

  IV fluids NS, DNS @ 50ml/ hr

Inj. Mannitol 100ml i.V/TID

Inj. Levipil 500mg iv/bd

Tab.Amlong 5mg PO/CD

Syrup. Potchlor 10ml in 1 glass water po/tid

GRBS 4th hourly monitoring

Vitals monitoring hourly

Inform SOS