A 65 year old female with Altered sensorium secondary to hypoglycemia

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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.

A 65 year old female from Miryalaguda was brought to the casuality with 

C/o Altered behaviour for an hour in the morning on 28th of November 2022.

History of presenting Illness 

According to the patient's Attendant

Patient was apparently asymptomatic 18 years back then she developed hip and knee pain. She used to go to another place to fetch water during which the pain was noticed. She was not on any medication for these complaints but used painkillers when the pain was severe.

About 13 years back she developed diminished vision in the right eye which gradually progressed to complete loss of vision within three years of onset.

About 6 years (2017) back she was started on Ayurvedic medicine (unknown) for her hip and knee pains and stopped the medication after 3 years of taking them (2019) as she observed generalised edema which subsided on stopping the Ayurvedic medicines

One year ago she developed decreased hearing in the right ear which was gradually progressive and continuous.

Since 3 to 4 months she's been using the support of any wall or a walker to walk.

6 days back she developed fever with no associating symptoms for one day which subsided on taking medication (crocin).

5 days back she developed pain during swallowing for both solids and liquids and was either drinking milk or eating an idly or two with difficulty and was also having slurred speech. 

One episode of vomiting consisting of food particles the day before presentation 

On 28th morning patient was observed to still be sleeping after waking her up she was talking irrelevantky, shouting and pulling her hair and had altered behaviour for an hour later she was fed Idly post which she calmed down but was drowsy and was brought to the casuality around 10:30 am but was coherent to time,place and person .

Past History

No similar complaints in the past

Not k/c/o Diabetes mellitus,Hypertension, Asthma,Tuberculosis, Hypo or Hyperthyroidism, Epilepsy , Seizures, CAD.

Family History

No significant family history 

Personal history

Patient used to be a telugu tutor initially but she stopped working as her pains increased gradually. Patient was unable to do her daily house chores comfortably because of her hip and knee pain

Her daily routine used to be waking up in the morning, watching television and do small chores and sleep

Patient had a low appetite as long as the Attendant remembers but appetite decreased further in the past 5 days due to pain during swallowing 

Sleep is adequate

Bowel and bladder movements were regular

No addictions.

Allergic history  - No known allergic history.

Surgical history  -  Did not undergo any surgeries 

General examination 

Patient was conscious, coherent and co-operative 

Conjunctival Pallor present 

No Icterus, Cyanosis, Koilonychia, Generalised lymphadenopathy, Pedal edema.

Vitals

Temperature - Afebrile 

Pulse rate - 90 bpm

Respiratory rate - 18 cpm

BP - 110/70 mm of Hg

SpO2 - 99% at room atmosphere 

GRBS - 134 mg/dL

Systemic examination 

CVS : S1 and S2 Sounds Heard

Respiratory: Bilateral Vesicular Breath Sounds Present

Abdomen : Soft and Non Tender

CNS :

GCS: E4V5M6

Orientation: oriented to time, place and person

MMSE : 19/30

Memory : Intact

Attention: Intact 

Speech : slurred

Calculation: intact 

Cranialnerves

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity  Left eye : Normal

                                   Right eye : PL +

          visual field is normal

          colour vision normal

3rd,4th,6th : pupillary reflexes present

                       EOM full range of motion present

5th : sensory intact

         motor intact

7th : normal

8th : Right side hearing is intact

         Left side decreased hearing

9th,10th : palatal movements present and equal.

11th,12th : normal.

Motor system 

Attitude - Lower limbs are flexed at the knee joint

Muscle tone: Right. Left

             UL.    Normal Normal 

             LL.     Normal Normal      

Muscle power: 

             UL. 5/5. 5/5

             LL        

Reflexes 

            Right Left 

Biceps 2+ 2+

Triceps 2+ 2+ 

Supinator 2+ 2+

Knee - -

Ankle - -

Plantar --

Knee,Ankle and Plantar reflexes were not elicited as the knees were in fixed flexion and patient complaints of pain on touching 

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal

Provisional Diagnosis

Altered mental status secondary to Hypoglycemia (recovered) with Dyselectrolytemia.

Investigations

Hemogram

Serum electrolytes

Serum Creatinine, Serum Urea

Serology

CUE

Urine electrolytes 

Thyroid profile

Chest X ray

USG neck

USG Abdomen 

ECG

Treatment: 

1. IV fluids 0.9%Nacl@30ml/hr

2. GRBS 6th hrly monitoring 

3. BP 2 bd hrly monitoring