74Female with altered sensorium

 74 YEAR OLD FEMALE PATIENT WAS BOUGHT TO CASUALITY WITH GENERALISED WEAKNESS SINCE 3 DAYS

HOPI:

PATIENT WAS APPARENTLY ALRIGHT 3 DAYS BACK

TODAY PATIENT ATTENDER SAW HER ON THE FLOOR WITH HER CLOTHES STAINED WITH

FAECES AND MICTURTION

NO FOOD INTAKE SINCE LAST 3 DAYS

NO C/O CHEST PAIN , FEVER , SOB , PALPITATIONS

NO VOMITINGS , LOOSE STOOLS

SHE IS ABLE TO LIFT HER HANDS AND LEGS

PAST HISTORY : N/K/C/O HTN , DM 2 , THYROID DISORDERS , CVA , CAD

PERSONAL HISTORY:

MIXED DIET

APPETITE LOST

BOWEL AND BLADDER - REGULAR

ADDICTION : REGULAR 180 ML DAILY ALCOHOL CONSUMPTION SINCE 10 YEARS

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS ,LYMPHADENOPATHY,EDEMA

VITALSTEMP- 99.9 F

PR- 124 BP

RR-22 CPM

BP-120/70MMHG

SPO2- 99% AT RA

CVS- S1,S2 HEARD , NO MURMERS

RS- BLAE PRESENT , NO ADDED SOUNDS

P/A- SOFT, NON TENDER

NO ORGANOMEGALY

CNS- RIGHT LEFT

TONE : UL N N

LL N N

POWER : UL 4/5 4/5

LL 4/5 4/5

REFLEXES BICEPS + 2 +2

TRICEPS +2 +2

SUPINATOR +1 +1

KNEE +2 +2

ANKLE +1 +1

PLANTAR F F

Investigation

2D ECHO DONE ON 3/10/23 :

TACHYCARDIA

NO RWMA MILD LVH + [ 1.23 CMS]

MILD TR + WITH PAH[ 33+10 = 43 MMHG ]

MODERATE AR + , TRIVIAL MR +

SCLEROTIC AV , THICKENED AV IAS - INTACT

EF = 57 % GOOD LV SYSTOLC FUNCTION

DIASTOLIC DYSFUNCTION + , NO AS/MS

MINIMAL PE +

IVC SIZE [0.7CMS] COLLAPSNG

USG DONE ON 2/10/23 IMPRESSION : GRADE 1 FATTY LIVER

Diagnosis ALCOHOLIC HEPATITIS HYPERTONIC HYPERNATREMIA SECONDARY TO DEHYDRATION (RESOLVED)

Treatment Given(Enter only Generic Name)

1.IVF NS , RL @ 100ML/HR

2.INJ OPTINEURON 1 AMP IN 100 ML NS IV /OD

3.INJ THIAMINE 100 MG IV /BD

4.TAB UDILIV 300 MG PO/BD

5.SYP LACTULOSE 15 ML PO / BD

Advice at Discharge

1.TAB.BENFOMET 100MG PO/OD X 1 WEEK

2.TAB UDILIV 300MG PO/BD X 1 WEEK

3.SYP.LACTULOSE 15ML PO/HS


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