61yr Female with Altered Sensorium -l

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.

PRESENTING COMPLAINTS:

- Stiffness of muscles of hands and neck 

- Slurred speech

- Deviation of mouth towards right.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10yrs back and then she developed dizziness, numbness and tingling sensation, burning sensation of hands and foot especially during night and was diagnosed with Diabetes Mellitus for which she is on medication. 

8months back she developed neck pain, headache, leg pain, body pains and was diagnosed with Hypertension for which she is on medication(not using regularly)

10 days back she developed fever, vomitings and weakness for which she went to local Area hospital and got treatment.

 From 2 days ago she was taking DM medication(OHA) without intake of food and at last night she suddenly developed altered sensorium and was brought to hospital.

HISTORY OF PAST ILLNESS:

Known case of DM since 10yrs

Known case of HTN since 8months

Not K/C/O TB, Epilepsy, Asthma, CAD

PERSONAL HISTORY:

Diet- Mixed 

Appetite- Decreased since 5days

Sleep- Inadequate 

Bowel and bladder movements- Irregular 

No Addictions 

No Allergies 

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

Patient is conscious, coherent, co-operative 

Pallor- present 

No Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema.

VITALS:

BP- 130/90mmhg

PR- 82bpm

RR- 16cpm

SpO2- 97% at room air

GRBS- 39mg/dl @ admission 

Temperature- 98.8F

Per Abdomen:

Inspection:- no scars seen.

Palpation:- No tenderness 

Percussion:- No free fluid.

Auscultation:- Bowel sounds heard.

SYSTEMIC EXAMINATION:

CNS :

No focal and neurological deficits

HMF -Normal

Pupils- Bilateral PSNL

GCS- E4V5M6

Sensory system:-

                            Right      left

Touch:                  N            N

Temperature:        N            N

Pressure:             N            N

Pain:                    N            N

Vibration:             N            N

Motor System:-

                      Upper limb                        Lower limb

               Right             Left                  Right          Left

Tone:      Normal        Normal            Normal      Normal

Power:           5/5           5/5                   5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                  +

Plantar         Flexion        Flexion

CVS:

S1,S2 heard 

No murmurs 

Respiratory System:

BAE+

Position of Trachea- Central

NVBS

No added sounds good 

INVESTIGATIONS:

2d-echo:

CHEST X-RAY:

ECG:

PROVISIONAL DIAGNOSIS:

Recurrent Hypoglycaemia (Oral Hypoglycaemic Agents induced);

Pre-Renal(non Oliguric) AKI;

Diabetes Mellitus-II with End organ damage (Retinopathy, Neuropathy- Glove and stocking + Gastroparesis, Nephropathy)