A 75 year old female with altered sensorium

July 19,2023

Hi,I am Athram Divya Sri 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

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