68/F with altered sensorium

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Cheif complaints:

Patient was brought to the casualty with the c/o altered sensorium since 2 days

HOPI:

Patient was apparently asymptomatic 2weeks back then she developed non bilious,non projectile vomitings 5 episodes food particles as a content associated with nausea treated with iv fluids at local hospital.loss of appetite,generalised weakness from 2days,altered sensorium worsened, intermittently gaining Orientation

No h/o fever,loose stools

No h/o constipation

H/o burning micturition

No h/o chest pain, palpitations,sob

No h/o seizures,loss of consciousness and headache.

K/c/o htn since 20 yrs on t.telmisartan 40mg+clinidipine+chlorothiazide 12.5mg

K/c/o dm since 20 yrs on t.glimiperide 1mg +metformin 500mg

O/e:

Patient is drowsy, 

MMSE:

Orientation to time:1

Orientation to place:2

Registration:3

Attention:0

Recall:2

Naming:3

Repeatation:0.5

Read and follow commands:1

Sentence:0.5

Copying:0

Score:13/30

Patient is conscious, but drowsy

Moderately built and nourished.

No signs of pallor, icterus, clubbing, cyanosis, pedal edema and lymphadenopathy.

Vitals:

Temp:98.6F

PR:84bpm

RR:19 cpm

BP:120/70mm.hg

Spo2:99%

GRBS:164mg/dl

SYSTEMIC EXAMINATION:-

Respiratory system:-

Bilateral air entry present 

NVBS heard

Cardiovascular system:-

S1, S2 heard

Abdomen:-

Soft, Non tender

CNS:-

NFND

CNS: 

GCS- E4 V4 M6

Power - 

         Rt. Lt

UL - 4/5 4/5

LL - 4/5 4/5

TONE 

UL - N. N

LL - N. N

Reflexes

B - 2+. 2+

T - 2+. 2+

S- 2+. 2+

K - 2+. 2+

A - 2+ 2+

Clinical images

ELECTROLYTES

26/5 27/5 28/5 29/5

Na+-130 135 140 141

k+- 3.3 3.2 3.5 3.5

cl- 95 98 105 99

Diagnosis

ALTERED SENSORIUM 

?DYSELECTROLYTEMIA

Plan of care

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) ARISTOZYME PO/TID

4)Inj.HUMAN ACTRAPID INSULIN S/C TID 

5)Tab. TELMISARTAN 40MG PO/OD 

6) SYP.CREMAFFIN PLUS 15ml/PO/STAT

7) Vitals monitoring 2  hrly

8) GRBS monitoring