A 70 YRS OLD FEMALE WITH ALTERED SENSORIUM

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

               CASE REPORT 

A 70 yrs old female patient who is a homemaker was brought to casualty with c/o ;

Altered sensorium since yesterday morning (10/8/23)

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic till yesterday morning back, then she had h/o altered sensorium after ingestion of OHA (TAB. GLIMI M1), after taking tablet she had her breakfast and after 1hr , she developed altered sensorium , then they called a local doctor to home for checkup , got her GRBS checked which was 30 mg/dl for which 25%dextrose was infused , patient’s sensorium improved.

She had h/o similar complaints again in the afternoon , her GRBS was 32 mg/dl, for which 25%dextrose was infused and was taken to the hospital and she had 2 episodes of hypoglycaemia.

No h/o fever, pain abdomen, burning micturition, vomiting.

PAST HISTORY : 

K/C/O Hypertension since 10 yrs ( on tab. AMLODIPINE 5 mg PO/OD + tab. ATENOLOL 50 msg PO/OD )

K/C/O DM type 2 since 7 yrs ( on tab. GLIMI M1 PO/OD )

Not a known case of CAD , CVA , epilepsy, TB , Asthma, thyroid disorders.

PERSONAL HISTORY:

Diet - Mixed 

Appetite - Normal 

Bowel Habits - irregular (once/2 days)

Bladder Habits - Regular

Sleep - adequate 

Addictions - none 

FAMILY HISTORY :

No H/O diabetes or hypertension in the family.

No significant family history.

DAILY ROUTINE :

Patient once worked as a farmer , but she stopped working since 4 yrs. she wakes up at around 8 am in the morning, freshen’s up and has her breakfast at around 10am. She usually stays at home all the day and helps her daughter in law if any. She has her lunch at around 1 30 pm. And has her dinner at around 9 pm whenever the food is prepared. Then she goes to bed at 11 pm. 

GENERAL EXAMINATION :

Patient is conscious , coherent and cooperative well oriented to time , place and person.

Moderately built and nourished.

Pallor - present  

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Oedema - absent

 

VITALS : 

Pulse - rate 78 beats per minute , regular rhythm.

Blood pressure - 140/70 mmHg 

Respiratory Rate - 20 cycles per minute 

Temperature - 98.4f

GRBS - 197 mg/dl

SPO2 - 98%

SYSTEMIC EXAMINATION :

PER ABDOMEN :

INSPECTION

- shape scaphoid

- No visible scars or sinuses 

- No visible gastric peristalsis 

PALPATION 

- No local rise of temperature 

- No tenderness

- No organomegaly

PERCUSSION 

AUSCULTATION 

- Bowel sounds heard 

CVS EXAMINATION : 

Shape of the chest - scaphoid

No visible pulsations 

S1 , S2 heard

Apex beat - left 5th intercostal space medial to mid clavicular line.

No murmurs 

CNS EXAMINATION : 

Patient is conscious, coherent and cooperative 

Speech - Normal

Cranial nerves - intact

Sensory system - Normal

Motor system :

                         Right                 Left

 Tone - UL :   Normal           Normal

              LL :    Normal           Normal

 Power - UL :    5/5                   5/5

                LL :     5/5                   5/5

 Reflexes -         Right           Left 

    Biceps :          ++                 ++

    Triceps :         ++                 ++

    Supinator :    ++                 ++

    Knee :             ++                 ++

    Ankle :             +                    +

Glasgow coma scale : 15/15

Plantar Reflex : Rt- Flexor  ; Lt- Flexor

Finger Nose coordination - Present 

RESPIRATORY SYSTEM :

Trachea - central

Shape of the chest - elliptical

Expansion of chest - symmetrical 

Bilateral air entry present , normal vesicular breath sounds heard.

PROVISIONAL DIAGNOSIS : Recurrent hypoglycaemia secondary to ?OHA with anaemia

INVESTIGATIONS ;

11/08/23 :

S.Creatinine - 1.1 mg/dl

Blood Urea - 21 mg/dl

S.Na - 140 mEq/L

S.K - 3.9 mEq/L

S.Cl - 104 mEq/L

Ca ionised - 1.14 mmol/L

RBS - 99 mg/dl

TREATMENT :

11/8/23 :

1)GRBS monitoring hrly

2)with hold OHA’s

3)if GRBS < 70 : Inj 25%D IV STAT

12/8/23 :

Diagnosis - Recurrent Hypoglycaemia secondary to OHA (Resolved) with Anaemia under the evaluation (Normocytic normochromic).

Treatment :

1)