75 year old female with altered sensorium

A 75 year old female with altered sensorium

July 19, 2023

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome

CHIEF COMPLAINTS:

 A 75yr old female resident of Podichedu , daily labour by occupation came to OPD with chief complaints of
Drowsiness and giddiness since 3days

HOPI:
patient was apparently asymptomatic 3days , then she started feeling drowsy and sleepy. She took 2 tablets of ranitidine at 2pm. She is drowsy but arousable.
No h/o altered behaviour, agitation, irrelevant talk, screaming.
No h/o fever,neck stiffness
H/o toddy consumption on 15/7/23

PAST HISTORY:
No h/o similar complaints in the past
Not a k/c/o HTN , DM ,CAD,Asthma, Epilepsy,TB, Thyroid disorders
H/o cataract surgery
H/O hysterectomy

PERSONAL HISTORY:
mixed diet

Normal appetite 

Regular Bowel and Bladder movements

Sleep -adequate

No allergies 

addictions - she consumes toddy 750 ml daily in summer season and 3 times a week in the other times

She ocassionally consumes whisky

H/O tobacco chewing 

FAMILY HISTORY:
Insignificant

MENSTRUAL HISTORY:
Attained menopause 20 years back
H/O hysterectomy 5 years back

General examination:
Slightly pallor 
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No pedal oedema
Vitals:
temp-afebrile

Pulse rate -88 bpm

RR-16 cpm

BP-90/60 mm of Hg

Spo2-97

GRBS-116

SYSTEMIC EXAMINATION:

CVS

S1,S2 present

NO MURMURS

RESPIRATORY SYSTEM-

BAE+

NVBS heard

Abdomen 

No tenderness 

CNS
Patient was conscious
Normal speech

INVESTIGATION:
ECG
USG Abdomen 




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