General medicine case
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A 69 year old female was brought to the casuality with chief complaints of sudden onset of aphasia preceded by 2 episodes of vomiting and staring look
History of present illness :
She was apparently asymptomatic and coherent after then she had 2 episodes of vomiting and after which she had difficulty in speech , generalised weakness , staring look at times ,difficulty in walking, walking with support , patient was unable to recognize her family members.
She had similar episodes of vomiting associated with weakness and disorientation 10 days back . She became stable when she was given adequate food and fluids at home in 2 days .
Past history:
No history of diabetes mellitus , hypertension , thyroid , epilepsy , seizures.
No history of surgeries
No history of fear , repetitive thought of action
Personal history :
Diet: mixed
Non alcoholic
No smoking habits
Appetite: decreased
Sleep : decreased
Family History:
No similar history in the family
Treatment history:
Not significant
General examination:
30/9/2021:
Conscious (confused)
Intermittent coherence
Speech: response to few commands
2/10/2021:
Irrelevant talk intermittently
No fresh complaints
4/10/2021:
Irritability and irrelevant talk reduced
Patient is able to recognise family members at times and hallucinating behaviour decreased
Vitals:
30/10/2021:
BP: 120/60 mm Hg
PR: 84bpm
1/10/2021:
Temp: Afebrile
BP:110/60mm Hg
PR: 88 bpm
2/10/2021:
Temp: 97.5 F
BP: 120/60mm Hg
PR: 86 bpm (regular)
3/10/2021:
Temp 97.5 F
BP: 110/80mm Hg
PR : 88bpm regular
Systemic examination:
1/10/2021:
CVS: S1 S2 + no murmur
RESP System: Resonated breath sounds in B/L ISA
P/A - soft, no tenderness
2/10/2021:
CVS: S1S2 + No murmur
Rs: NVB1 decreased breath sounds in lt RSA
P/A soft, no tenderness
I/O 2200/1600 ml
GRBS 152 mg/dl
3/10/2021:
CVS: S1S2 + No murmur
Rs: NVB1 decreased breath sounds in lt RSA
P/A soft, no tenderness
I/O 1550/1400 ml
GRBS 150mg/dl
Investigations :
Complete blood picture :
MRI :
ECG :
CBP , Serum electrolyte , LFT
Other investigations:
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