78 y/o female with giddiness and history of fall

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient -centered online learning portfolio and your valuable inputs on the comment box"

  
This is a case of 78 yr old female who was brought to the hospital with history of giddiness since 3 days 
She had history of fall 3 days ago following with she had an injury on left hand.
She was unable to walk since 1 day
She was having drowsiness & vomitings since today morning. 

HOPI
She was apparently normal 8 days back when she had giddiness and history of fall , following which she sustained injury to the left hand where she developed swelling, blebs 
and had difficulty in walking.
√She had complaints of vomitings 2 episodes with food as content.
√she was given Ceftriaoxne for 3 days by local RMP. 

•PAST HISTORY
√ She has a history of admission in hospital in February, with complaints of vomitings, altered sensorium no clear history about the treatment is known.

√ history of diabetes since 10-15 years and is on 
√history of  hypertension since 10 years and is on
√not a k/c/o asthma, Tb, CAD, epilepsy
TREAMENT HISTORY:-
She was on unknown medication for hypertension & diabetes. 

•PERSONAL HISTORY
Diet - mixed
Bowel and bladder - Regular
Appetite  - normal
Sleep  - adequate
Addiction- Nil

•FAMILY HISTORY
Not significant

EXAMINATION:-
Pt was drowsy, oriented to time, place, person
No pallor, icterus, cyanosis, lymphadenopathy. 
Temp- 98.6f
Bp- 130/90mmhg
PR- 85 bpm
RR- 18 cpm
Spo2-98% at room air
GRBS- 104 mg/dl

SYSTEMIC EXAMINATION:-
CVS- S1 S2 +
R/S - BAE +, NVBS
P/A -DISTENDED ABDOMEN, NON TENDER. 
CNS-  DROWSY, ORIENTED TO TIME, PLACE, PERSON. 
                 RT           LT
BICEPS - 2+            2+
TRICEPS 2+           2+
SUPINATOR 1+       1+
KNEE           1+        1+
ANKLE         -           -
PLANTAR   -WITHDRAWAL  IN BOTH LIMBS. 

DIAGNOSIS:-
LEFT UPPERLIMB CELLULITIS
ALTERED SENSORY 2° TO UREMIC ENCEPHALOPATHY





















TREATMENT:-
(1) INJ. PIPTAZ 2.25 gm IV/TID
(2) INJ. METROGYL 100 ml IV/TID
(3) INJ. ZOFER 4mg IV/sos
(4) IVF NS, RL@ 100ml/hr
(5) TAB. SHELCAL PO/RT/OD
(6) INJ. HAI S/C ACC TO GRBS
(7) Mgso4+ glycerinr dressing now. 
(8) RT FEEDS 200 ml milk + 100ml NS 4 th hrly
With protein powder. 
(9) INJ. OPTINEURON 1amp + 100 ml NS /IV/OD



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