ll Internal Assessment Examination.

Altered sensorium secondary to hypoglycemia , dyselectrolytemia.

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A 65 year old female patient resident of Nalgonda Telugu tutor by occupation was bought to casualty with chief complaints of altered behaviour  for an hour in the morning on28/11/2022

History of presenting Illness:

Patient was apparently asymptomatic 20  years back then she developed Bilateral Hip and knee pains which was insidious in onset gradually progressed  aggravated on doing work and relieves temporarily on taking medication   ,she stopped working as Telugu tutor because of the pain.

Patient developed diminision of vision in Right eye  since 14 years which has led to complete loss of vision  10 years back . Perception of light is present.

She took some ayurvedic treatment (unknown)for 3 years(2016-2019) after that she developed generalized edema all over the body , stopped the medication on doctor's advice.

She used pain killers once in a while 

 It is now progressed to such an extent that it has caused fixed flexion deformity bilaterally . Patient walks with the help of Walker since 3-5 months.

Patient was apparently asymptomatic 6 days back fever  decreased on taking medication (crocin) , She had odynophagia the next day  for both  solids and liquids ,she hardly takes any food,she took 1-2 idli and glass of milk  .

She also complained of nausea,nonprojectile vomiting with food particles as the content,non blood stained.

On 28/11/2022 

Patient started shouting in the morning around 8 am ,started pulling her hair  and talking irrelevantly  with her family members ,after feeding two idlis she was calm for a while she was taken to the hospital around 10:30 am , patient was semiconscious and coherent on her way to the hospital.

Past History:

No similar complaints in the past .

Not a known case of Diabetes , hypertension, Tuberculosis, Epilepsy,asthma,Coronary artery disease .

Family History:

No significant family History

Personal History:

Appetite: decreased ( she always had less appetite),diet- mixed, bowel and bladder movements - regular ,sleepi is adequate and no addictions 

On General examination:

Patient was semi conscious coherent and cooperative

Moderately built and nourished 

pallor present

 ,No, Icterus, Cyanosis,

 Clubbing, generalized lymphadenopathy

 bilateral pedal edema 

Vitals: On the day of admission -

Pulse rate: 96bpm

Blood pressure:110/70mmHg

Temperature:afebrile

Respiratory rate:20cpm

Blood Glucose:50mg/dl

At 6pm:             138mg/dl 

At8pm:                181mg/dl 

Systemic Examination:

Central nervous system examination :

Consciousness: conscious

GCS: E4V5M6

Orientation: oriented to place time and person 

Memory:

Immediate: intact 

Recent: intact 

Remote:intact 

Attention: intact 

Calculation: intact 

Cranial nerves: intact

Motor system :

Muscle tone: Right                 Left

             UL           N.                     N

             LL            N.                    N

Muscle power: 

             UL   -5/5    Right    5/5 Left

             LL        - cannot be assessed because of Flexion deformity of lower limbs.

Reflexes 

                          Right          Left 

     Biceps             2+             2+

      Triceps           2+            2+ 

    Supinator         2+.              2+

Knee - -

Ankle - -

Superficial reflexes and deep reflexes are present , normal.

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal

Mini mental status examination:19/30

Per abdomen:

Inspection:

No Abdominal distension 

No scars, sinuses, mass visible

Palpation:

Inspectory findings are confirmed 

No local rise of temperature

Tenderness absent

Cardiovascular system examination :

Inspection : Bilaterally symmetrical chest present 

No scars, sinuses

Palpation:

Inspectory findings are confirmed

Apex beat normal

On Auscultation : 

S1 S2 heard

No murmurs or additional heart sounds

Diagnosis:

 Altered sensorium secondary  to        hypoglycaemia (recovered) with dyselectrolytemia.

INVESTIGATIONS: 

On28/11/22

On 30/11/22

Usg Abdomen 

Usg of NECK:

COLOR DOPPLER 2D echo 

Ecg :

2/12/22

Treatment: 

1.I.v fluids 0.9%Nacl@30ml/hr

2.GRBS 6th hrly monitoring 

3.BP 2 bd hrly monitoring