69 YEAR OLD FEMALE
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I've 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 come up with a diagnosis and treatment plan.
69 year old female
C/O unable to recognise family members since 5 days
C/O vomiting
Irrelevant talk since 2 days
Patient was apparently assymptomatic 5 days back ,then she had 2 episodes of vomiting after which she had difficulty in speech and generalised weakness,staring look at times, difficulty in walking, patient is unable to recognise her family members .
Patient was bought to the hospital for further evaluation .
Patient has slurring of speech and patient is passing urine and stools involuntarily.
No h/o seizure,head injury
No h/o fever
H/O similar epusode 10 days back
Not a k/c/o DM,HTN, Thyroid,Asthma
O/E
Pt c/c/c
Oriented only to person
Irrelevant talk present intermittently
BP:110/70 mmHg
PR:80 BPM
CVS:S1S2 HEARD
no murmurs
RS: decreased breath sounds in b/l ISA
P/A:soft non tender
CNS:
SPEECH- Irrelevant intermittently
Pupils-NS RL
MMSE couldn't be performed
MOTOR
Power-4/5 in B/L UL and LL
Tone-
R L
UL incd. Incd
LL incd. Incd
Reflexes-
B T S A K P
R 2- - - - - flexion
L 2- - - - - flexion
INVESTIGATIONS:
XRAY
XRAY
ECG:
MRI:
DIFFUSE CEREBRAL ATROPHY
ON 01/10/21
SERUM ELECTROLYTES:
Na-127 K-4.5 Cl-104
ON 02/10/21
Serum electrolytes:
Na-132 K-3.8 Cl-92
Serum osmolarity-291 m osm
URINARY ELECTROLYTES:
Na-161 K-35.7 Cl-181
Urinary protein-12
Spot urine creatinine -82.5
03/09/21
Serum electrolytes:
Na-135 K-3.9 Cl-91
04/10/21
Na-135 K-3.9 Cl-91
DIAGNOSIS:
CHRONIC HYPONATREMIA
? DEMENTIA
PSYCHIATRY REFFERAL:
TREATMENT:
Treatment on day 1
IVF NS ,RL WITH 1 OPTINEURON @75 ML /HR
INJ.PAN 40MG IV/OD
INJ ZOFER 4MG /IV/SOS
TAB DOLO 650 MG PO/SOS
SYP ASCORYL 10 ML /PO/TID
INJ MONOCEF 1GM /IV/BD
Treatment on day 2
IVF NS ,RL WITH 1 OPTINEURON @75 ML /HR
INJ.PAN 40MG IV/OD
INJ ZOFER 4MG /IV/SOS
TAB DOLO 650 MG PO/SOS
SYP ASCORYL 10 ML /PO/TID
INJ MONOCEF 1GM /IV/BD
Treatment on day 3
IVF NS ,RL WITH 1 OPTINEURON @75 ML /HR
INJ.PAN 40MG IV/OD
INJ ZOFER 4MG /IV/SOS
TAB DOLO 650 MG PO/SOS
SYP ASCORYL 10 ML /PO/TID
INJ MONOCEF 1GM /IV/BD
TAB ADMENTA 10MG OD(8AM)
TAB OLANZAPINE 5MG OD/HS
INJ HALOPERIDOL 1/2 AMPOULE /IM/SOS
Treatment on day 4
IVF NS,RL WITH 1 OPTINEURON @75ML /HR
INJ.PAN 40MG IV/OD
INJ ZOFER 4MG /IV/SOS
TAB DOLO 650 MG PO/SOS
SYP ASCORYL 10 ML /PO/TID
INJ MONOCEF 1GM /IV/BD
TAB ADMENTA 10MG OD(8AM)
TAB OLANZAPINE 2.5MG OD/HS
INJ HALOPERIDOL 1/2 AMPOULE /IM/SOS
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