75 year old female with altered sensorium second to cellulitis
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A 75 year old women came to causality on 10/01/23 with
CHIEF COMPLAINT:
C/ofever since one week
SOB since one week
cough since 1 month
K/C/O cellulitis - surgery done 1 month back
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 years ago and then developed minor abrasion to right lower limb and then developed right lower limb swelling till knee and was diagnosed to be having right lower limb cellulitis and fasciotomy was done and resolved .she was normal from then and 1 month back she developed sudden swelling of left lower limb till knee intially and then progressed to thigh.she went to local hospital and found to have left lower limb cellulitis and on further evaluation found to be having erosion of knee and was diagnosed septic arthritis and incision and drainage was done and left knee osteotomy was done , fasciotomy and debridement of left lower limb was done.20 pRBC'S transfusions was done and daily dressing was done.since 10 days she developed fever which was incidious in onset,high grade,with chills and rigor.she developed SOB since 1 week and also was on altered sensorium since 1 week .
PAST HISTORY:
K/C/O DMT2 on Tab zorylmv1(metformin 500 mg +glimeperide 1mg+ voglibose 0.2mg) since 3 years.
Not a K/C/O HTN/asthma/TB/Epilepsy/CAD/CVA/Thyroid disorders.
K/C/O right limb cellulite 3 years ago
MENSTRUAL HISTORY:
Age of menarche: 13 years
Age of menopause: 50 years
PERSONAL HISTORY:
Appetite: normal.
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions: no addictions
GENERAL EXAMINATION:
Patient is drowsy but arousable.
Pallor: present
Icterus:abesnt
Cyanosis:absent
Clubbing: absent
Lympadenopathy:absent
Edema:absent
VITALS:
Temp: 97.7F
Bp:120/70mmhg
PR:90bpm
RR:16cpm
Spo2:97
GRBS:211mg/dl
SYSTEMIC EXAMINATION:
Respiratory- B/L air entry present; diffuse wheeze present
CVS- s1s2+ no murmur
P/A soft non tender
CNS- patient is drowsy
Pupils- left- NSRL
right-NSRL
Higher mental functions
- Conscious +
- Oriented to time - ,place+ and person+
- Memory - intact
- Speech - normal
Cranial nerve examination
• 1 - olfactory sense - normal
• 2- visual acuity present,
R L
Direct reflex +. +
Indirect reflex + +
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present
• 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present
• 8- Normal hearing
• 9,10- position of uvula is central ,Gag reflex- present
• 11- sternocleidomastoid contraction present
• 12- no deviation of tongue
Motor system
Reflexes
Right Left
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 3+ -
Knee. 3+. 3+
Ankle. - -
Plantars- Extension Extension
Power. Lt. Rt
Upper limb -5/5. 5/5
Lower limb -5/5 5/5
TONE. Lt. Rt
Upper limbs N N
Lower limbs N N
No Involuntary movements
SENSORY SYSTEM
R L
1. Crude touch N N
2. Pain. N. N
3. Temperature. N. N
INVESTIGATIONS:
On 10/01/23
ECG on 10/01/23
Diagnosis:
Altered sensorium secondary to septic encephalitis secondary to left lower limb cellulitis with left knee Septic arthritis with diabetic mellitus type 2 with
Anemina under evaluation with grade 1 bedsore
left knee aspiration on 10/12/23
lumbar puncture on 11/12/23.
Wedge biopsy on 13/12/23
1. Iv fluids NS RL with 1amp optineuron @50ml/hr.
2.RT feeds- 50ml milk with protein powder and 100 ml water 2nd hourly
3.inj.meropenem 500mg/iv/BD
4.inj.vancomycin 1gm/iv/bd in 100ml NS over 45min.
5. Inj. Pan 40mg IV/OD
6.Inj. Zofer 4mg/IV/OD
7.inj.Human Actrapid insulin s/c /TID
8.inj Lasix 40 mg/IV/BD
9.Tab.Olanzapine 2.5mg/RT/TID
11.NEB with Budecort and Mucomist 6th hourly
12.left lower limb dressing
13..bp temp monitoring 2nd hrly
14.Tab Orofer-XT/RT/OD
