78 years old female with giddiness and a history of fall
This is a case of 78 yr old female who was brought to the hospital with history of giddiness since 3 days
She had history of fall 3 days ago following with she had an injury on left hand.
She was unable to walk since 1 day
She was having drowsiness & vomitings since today morning.
• HOPI
√She was apparently normal 8 days back when she had giddiness and history of fall , following which she sustained injury to the left hand where she developed swelling, blebs
and had difficulty in walking.
√She had complaints of vomitings 2 episodes with food as content.
√she was given Ceftriaoxne for 3 days by local RMP.
•PAST HISTORY
√ She has a history of admission in hospital in February, with complaints of vomitings, altered sensorium no clear history about the treatment is known.
√ history of diabetes since 10-15 years and is on
√history of hypertension since 10 years and is on
√not a k/c/o asthma, Tb, CAD, epilepsy
TREAMENT HISTORY:-
She was on unknown medication for hypertension & diabetes.
•PERSONAL HISTORY
Diet - mixed
Bowel and bladder - Regular
Appetite - normal
Sleep - adequate
Addiction- Nil
•FAMILY HISTORY
Not significant
EXAMINATION:-
Pt was drowsy, oriented to time, place, person
No pallor, icterus, cyanosis, lymphadenopathy.
Temp- 98.6f
Bp- 130/90mmhg
PR- 85 bpm
RR- 18 cpm
Spo2-98% at 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, PERSON.
RT LT
BICEPS - 2+ 2+
TRICEPS 2+ 2+
SUPINATOR 1+ 1+
KNEE 1+ 1+
ANKLE - -
PLANTAR -WITHDRAWAL IN BOTH LIMBS.
DIAGNOSIS:-
LEFT UPPERLIMB CELLULITIS
ALTERED SENSORY 2° TO UREMIC ENCEPHALOPATHY
CLINICAL IMAGES:-
Date: 29/9/22
Date: 30/9/22
Date:01/10/22
Date:03/10/22
Date:04/10/22
TREATMENT:-
(1) INJ. PIPTAZ 2.25 gm IV/TID
(2) INJ. METROGYL 100 ml IV/TID
(3) INJ. ZOFER 4mg IV/sos
(4) IVF NS, RL@ 100ml/hr
(5) TAB. SHELCAL PO/RT/OD
(6) INJ. HAI S/C ACC TO GRBS
(7) Mgso4+ glycerinr dressing now.
(8) RT FEEDS 200 ml milk + 100ml NS 4 th hrly
With protein powder.
(9) INJ. OPTINEURON 1amp + 100 ml NS /IV/OD
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