80yr old female with Altered sensorium and CKD with late onset psychosis b/l osteoarthritis of knee

This is a paper based log book (with a corresponding E log version online) to discuss our patients de-identified health data, shared after taking his/her/guardian’s signed informed consent (check out the multilingual informed consent form template in the subsequent pages ahead). Here we discuss our individual patient’s problems through series of inputs from available local and global online community of learners and teachers with an aim to solve these patient’s clinical problems with collective current best evidence based inputs. This log book also reflects my patient- centered learning Portfolio, also available as an online learning portfolio and your valuable peer review inputs will enable me to learn further as to help our patients better.

80 yr old female was brought to the casualty with Chief complaints of 
   .Fever since 2 days
  . Altered sensorium since 2 days
   .loss of appetite since 2 days
Hopi: patient was apparently asymptomatic 2 days ago then she had fever high grade not associated with chills and rigor relieved with medication no diurnal variation altered sensorium since 2 days, irrelevant talk present.not able to identify the attenders,no h/o loss of consciousness, weakness in upper and lower limbs,no h/o chest pain palpitations sob,
loss of appetite and weight 
K/c/o HTN on tab atenolol
Kc/o ckd on conservative management
K/c/o AkI on CKD secondary to ruptured gluteal abscess 
With late onset psychosis

PERSONAL HISTORY-

Diet - Mixed 
Appetite - Decreased 
Bladder movements- Regular
Bowel movements- Regular
Sleep - Adequate
Allergy - No
Addictions - No
Family History:Not significant

General examination:
Patient is conscious 
No pallor,icterus,cyanosis,clubbing, lymphadenopathy 
PR:102/min
BP:100/60mmhg
RR:20/min
SPO2:94%


Systemic examination
CVS:S1 S2+. No murmurs
RS:BAE+
CNS
GCS:E4V4M6
Power:     Rt.  Lt
         UL.  cannot be elicited 
         LL.  cannot be elicited 

Tone. 
           UL.     N.    N  
            LL.      N.    N
Reflexes:
             B.    3+.     3+
             T.     3+.       3+
             S       2+.      2+
             K.      3+.      3+
             A.      2+.      2+
       Plantar flexion.  flexion 
P/A.     Soft,non tender

Investigations
Hb:8.4 gm/dl
TC:33200
PCV:26.0
RBC Count:2.65 millions
PLT COunt:2.73lacs
Urea:106
Creatinine:2.7
Uric acid:8.0
Ca:10.0
P:5.1
Na:139
K:4.1
Cl:101
CRP:positive
Blood lactate:5.9
CSF analysis
Sugar:61
Protein:9.5
Chloride:116
RBS:86
LFT :Total bilirubin :2.05
DB:0.42
Alkaline phosphate :162
ApTT test:35sec

                        Chest xray
                                ECG

 Provisional diagnosis :
Altered sensorium secondary to PYOGENIC MENINGITIS with AKI 



Treatment
 1.Ryles tube feed
 100ml water 2nd hrly
200ml milk 4th hrly
2.100ml NS
3.Inj .CEFTRIOXONE 1gm IV/BD
4.Inj.CLINDAMYCIN 600mg IV/BD
5.Inj.PAN 40mg IV/OD
6.Tab.NODOSIS RT/OD
7.Tab SHELCAL 500mg RT/OD
8.Tab.OROFER-XT RT/OD
9.Inj.DEXAMETHASONE 6mg IV/TID
10.Monitor vitals 2 nd hrly nd inform SOS
11.Strict input/output charting
 







Comments

Post a Comment

Popular posts from this blog

58 yr old male with neck pain and B/L knee pain

Image
This is a paper based log book (with a corresponding E log version online) to discuss our patients de-identified health data, shared after taking his/her/guardian’s signed informed consent (check out the multilingual informed consent form template in the subsequent pages ahead). Here we discuss our individual patient’s problems through series of inputs from available local and global online community of learners and teachers with an aim to solve these patient’s clinical problems with collective current best evidence based inputs. This log book also reflects my patient- centered learning Portfolio, also available as an online learning portfolio and your valuable peer review inputs will enable me to learn further as to help our patients better. A 58 yr old male farmer by occupation came with cheif complaints of  Neck pain since 2-3 weeks B/L knee pain since 3 months Hopi Pt was apparently normal 8 months back then he had c/o  chest pain SOB grade 3 then he consulted a private hospital wh
Read more

19yr old female with fever and cough

Image
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 best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.  A 19 year old female resident of warangal,  came to the OPD with chief complaints of fever and cough since 10 days HOPI: Patient was apparently asymptomatic 7 months back she had fever associated with joint pains and swelling for which she was diagnosed to be SLE and symptoms subsided with medication      now she had complaints of fever since 15 days which is continuous highgrade and non productive cough No h/o vomitings, diarrhoea, burning micturition Past history :  has no hist
Read more