a 75 yr old female

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A 70 year old female home maker since 10-15 years (farmer by occupation) came to causality in drowsy state.

HOPI: Patient was apparently asymptomatic 10 years back ,then patient had h/o fall for which she went to local hospital there she got diagnosed with DM and since then she is on OHA medication(glim m2).4 years back she had h/o fall and went to hospital and got diagnosed with HTN. 1 session of dialysis was done (indication/cause unknown ) .Patient wasn’t on any medication for HTN .1 month back she developed hypoglycaemia secondary to OHA’s ,then resolved later.Patient had h/o fall 4 days back ,fracture of IT femur right leg operated(? ORIF done).On POD 2, patient was drowsy ,opening eyes to deep pain .Since yesterday ,she is unable to recognise patient attenders.

PAST HISTORY: 
K/C/O  DM since 10 years & on medication.
K/C/O HTN since 4 years

GENERAL EXAMINATION: 
O/E : Patient is responding to vocal commands
Pallor - present
Icterus  absent
Cyanosis - absent
Edema of feet - present
Lymphadenopathy  - absent
Clubbing - absent

VITALS:- 
 BP: 170/90mmhg
 PR: 98 bpm 
 RR: 25cpm 
 Spo2: 95%
 Grbs: 146

SYSTEMIC EXAMINATION : 
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 
RESPIRATORY SYSTEM : BAE present
P/A : soft 
CNS: Pt is drowsy.
tone : normal

INVESTIGATION:

12/2/22

D dimer: 6910ng/ml
BGT: B POSITIVE
ESR :. 140
RBS: 220
APTT: 30 seconds
PT : 15 seconds
INR: 1.11

USG abdomen 

ECG 

CT BRAIN 

VENOUS DOPPLER OF RIGHT LOWER LIMB

LFT 




PROVISIONAL DIAGNOSIS:
? uraemic encephalopathy with pre renal AKI with POD 4 right femur fracture ?CRIF PFM with DM and HTN

TREATMENT:
1. INJ. Lasix 40mg IV/BD
2. INJ. HAI SC/TID 
3. INJ. CEFTRIAXON 1g/IV/BD
4. INJ. CLINDAMYCIN 600mg/ IV /TID
5.INJ. CLEXANE 20 mg SC/OD
6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD
7.TAB. Amlong 10mg PO /OD
8.IVF NS UO 30 ml/hr

SOAP NOTES:-
DAY 2: 

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