65 yr old female with loss of consciousness

July 01, 2022

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CHEIF COMPLAINTS:
My case is a 65 year old female came to the casualty on 28.06.22 with generalised weakness and decreased speech since 2 days.

[ ] HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 years back then she developed polyuria and fever for which she went to hospital and she was diagnosed as diabetic for which she had started on oral hypoglycemia drugs.
......6 years back she had fever associated with cough and expectoration for about 10 days for which she was diagnosed as as tuberculosis and was started on antitubercular treatment for 6 months and later became negative for tb.
.........1 year back she had an episode of loss of consciousness and when she was examined was found to have low blood sugar levels and was treated conservatively by a local RMP doctor
.........6 months back she developed fever and pedal edema which is of pitting type for which she visited hospital was found to have renal pelvic dilatation and deranged renal function tests.
.........2months back she had an episode of loss of consciousness for which she was found to have low GRBS and was treated conservatively and also found to have grade 2 Renal pelvic dilation changes in bilateral kidney and her renal function tests also changed .

[ ] PAST HISTORY:
Not a known case of hypertension, CAD,Asthma,epilepsy.

[ ] FAMILY HISTORY:
Not significant.
[ ] PERSONAL HISTORY:
Diet :mixed
Appetite:normal
Sleep :adequate
Bowel and bladder:regular.
No addictions

[ ] GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative
Moderately built and poorly nourished
Well oriented to time place and person.
No pallor ,icterus ,edema ,cyanosis, lymphadenopathy.
VITALS:
BP:110/70mmhg
PR:74bpm
RR:16cpm
Temp:afebrile.
[ ] SYSTEMIC EXAMINATION:
CVS:S1,S2 HEARD,NO MURMURS
CNS:NO FOCAL NEUROLOGICAL DEFICITS
PA:SOFT AND NONTENDER
RS:BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS.