A 75 year old female with altered sensorium
75 year old female with altered sensorium
July 19,2023
Hi,I am Arundathi 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
CASE SHEET
CHIEF COMPLAINTS:
A 75yr old female resident of Podichedu , daily labour by occupation came to OPD with chief complaints of
Drowsiness and giddiness since 3days
HOPI:
patient was apparently asymptomatic 3days , then she started feeling drowsy and sleepy. She took 2 tablets of ranitidine at 2pm. She is drowsy but arousable.
No h/o altered behaviour, agitation, irrelevant talk, screaming.
No h/o fever,neck stiffness
H/o toddy consumption on 15/7/23
PAST HISTORY:
No h/o similar complaints in the past
Not a k/c/o HTN , DM ,CAD,Asthma, Epilepsy,TB, Thyroid disorders
H/o cataract surgery
H/O hysterectomy
PERSONAL HISTORY:
mixed diet
Normal appetite
Regular Bowel and Bladder movements
Sleep -adequate
No allergies
addictions - she consumes toddy 750 ml daily in summer season and 3 times a week in the other times
She ocassionally consumes whisky
H/O tobacco chewing
FAMILY HISTORY:
Insignificant
MENSTRUAL HISTORY:
Attained menopause 20 years back
H/O hysterectomy 5 years back
General examination:
Slightly pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No pedal oedema
Vitals:
temp-afebrile
Pulse rate -88 bpm
RR-16 cpm
BP-90/60 mm of Hg
Spo2-97
GRBS-116
SYSTEMIC EXAMINATION:
CVS
S1,S2 present
NO MURMURS
RESPIRATORY SYSTEM-
BAE+
NVBS heard
Abdomen
No tenderness
CNS
Patient was conscious
Normal speech
INVESTIGATION:
ECG
USG abdomen
