A 70 year old female with history of self fall
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A 70 year old female who is a resident of narammagudem who was a Home maker from 10-15 years (before which she was a farmer).
CHIEF COMPLAINTS:-
She came to the casuality in drowsy state.
History of presenting illness(HOPI):-
Patient was apparently asymptomatic 11 years back then she was diagnosed with hypertension
Then After 1 year she had a history of losing consciousness and fell down for which she went to local hospital where she was diagnosed with diabetes mellitus and since then she in OHA medication (glimiperide M 2) .
4 years back she had an history of fall then she went to local hospital where she was referred to our hospital but here due to some issues she was referred to Hyderabad were she had 1 session dialysis once ( reason unknown) and again patient attenders brought back the patient to our hospital and she was treated and sent home.
She had a history of intermittent headache(no history of trauma) for which she took zandu balm and got relieved .
She also used spects for headache and sight which she is not using now.
1 month back she developed hypoglycemia secondary to OHA's , then resolved later.
7 days back she had and history of fall again and fracture of right femur. Then she was taken to a local hospital and was operated to that leg
( ORIF ) .After 2 days she became drowsy can't open eyes fully and was in pain.so they done some tests and referred to a higher centre so they came to our hospital.
At the time of admission of patient was drowsy
And can't recognise the patient attenders.
No H/O of any fever, nausea , vomitings, loss of appetite.
PAST HISTORY:-
She has hypertension since 11 years and diabetes since 10years for which she is using medication.
No history of thyroid,CAD,CKD,asthma,TB
Hepatitis.
Medication she used before admission:-
FAMILY HISTORY:-
No significant family history
SOCIAL HISTORY:-
She is the only person in the house who cooks on her self and does her regular activities.
Drug history:-
No history of any kind of allergies to any kind of drugs .
Marital history:-
Her husband died of heart attack 20 years back.She had 5 children of which 3 daughters and 2 sons.
Edema:-
Fractured and operated leg:-
EXAMINATION:-
GENERAL EXAMINATION:-
Patient was drowsy.
She was moderately built and moderately nourished.
Pallor - present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Oedema of feet - present( pitting type)
Lymphadenopathy- absent
Vitals on admission:-
BP :- 170/90 mmHg
PR:- 98
Respiratory rate :- 22 cpm
Spo2 :- 95
GRBS :-176
SYSTEMIC EXAMINATION:-
CVS :- S1; S2 heard ; no murmers
Respiratory system:- Bilateral air entry present
Per abdomen:- soft
CNS :- patient is drowsy
Tone is normal
INVESTIGATIONS:-
Abnormalities found in lab investigations:-:
On 12/02/2022:-
Hb:- 5.8
TLC:- 11,000
Smear :- microcytic hypochromic anemia
RBS :- 220
ESR :- 140
Blood urea :- 143
On 13/02/2022:-
Hb :- 6.1
TLC :- 11,500
In between she had a blood transfusion done
On 15/02/2022
Hb:- 8.2
TLC :- 40,000
PCV :- 23
RDW - 18
Blood grouping and Rh type :-
APTT:-
ESR:-
Haemogram:-
On 15/02/2022:-
Prothrombin time (PT) :-
D- Dimer:-
Ultrasound report :-
On admission:-
On 15 /2/2022 :- ( abdominal distention)
Ultrasound report ( right lower limb):-
CT - scan ( brain):-
PROVISIONAL DIAGNOSIS:-
Uremic encephalopathy with pre renal AKI with post operative delirium 4 right femur fracture.
PLAN :-
1. INJ. Lasix 40mg IV/BD
2. INJ. HAI SC/TID
3. INJ. CEFTRIAXON 1g/IV/BD
4. INJ. CLINDAMYCIN 600mg/ IV /TID
5.INJ. CLEXANE 20 mg SC/OD
6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD
7.TAB. Amlong 10mg PO /OD
8.IVF NS UO + 30 ml/hr
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