42 year old male with altered sensorium

 

August 16th,2022


Chief Complaint :

A 42 year old male was brought to casuality in a state of altered sensorium with history of fever since 10 days , vomiting since 10 days , generalised weakness and drowsiness since 10 days.
HOPI :
Patient was asymptomatic 1.5 years ago and then developed involuntary movements of upper limb and lower limb associated with uprolling of eyes and for which he was taken to a local hospital and was diagnosed to be having alcoholic encephalopathy and dyselectrolytemia treated conservatively and was discharged in a hemodynamically stable condition. From them he was asymptomatic until 10 days ago , when he developed fever which is of low grade and relieved on medication and developed generalised weakness and vomiting 4-5 episodes in a day and the content are food particles and nom- bilious and also associated with nausea. C/O generalised weakness and drowsiness since 10 days. With above complains patient visited multiple hospitals and received symptomatic treatment in the past 10 days and came to our hospital on 10/08/2022 for further management .
- No H/O headache , giddiness , seizures 
- No H/O pain abdomen, loose stools 
- No other complains 
Past History 
Not a known case of DM and HTN
Personal History
- Mixed diet
- decreased sleep and appetite 
- chronic alcoholic 
Family history
Not significant.
Vitals at admission :
BP: 60/50
PR: 74bpm
RR: 16cpm
GRBS: 84mg/dL
RS: BAE + clear
CVS: S1,S2 heard
P/A: soft, non-tender
CNS: Patient is drowsy, but arousable 
E3V4M6
- No signs of meningeal irritation 
- NFND









Fever chart




Investigations










11/08/2022







12/08/2022





13/08/2022






Blood Urea :12mg/dL
S. Creatinine : 0.5mg/dL

14/08/2022







15/08/2022



Morning



Evening



16/08/2022
Morning 









Evening



17/08/2022





18/08/22
Morning







19/08/22 
Morning






Plan of care-
 1.IV fluids
0.9%NS@150ml/hr
2.Inj.pantop 40mg iv/OD
3.Inj.zofer 4 mg iv/sos
4.Inj.neomol 100ml iv/sos
(If temp is more than 101 degree F)
5.Inj.thiamine 100mg iv/tid
6.Inj.cetriazone 2Gm iv/bd
7.Inj.Lorazepam2 cc IV (if seizure episode)
8.Inj.Levipil 500mg iv/bd
9.inj.meropenam iv/Bd (day 4)
10.Tab.Dolo650mg po/tid
.Monitor vitals-4rth hourly
  I/O charting








Popular posts from this blog

Intern online Assessment

Image
  Intern assessment    Name : B.Sushma Posted from 11/8/2022 till 11/10/2022 Current online learning portfolio (OLP) linked here 👉 bonthusushma154.blogspot.com Learning impact assessment from cases recorded  in OLP : CASE 1)   51 year male with foot drop and ulcer https://bonthusushma154.blogspot.com/2022/09/51-year-old-male-with-foot-drop.html Learning impact-- Discussion in class: Question 1: Why was biopsy not done in ulcer region i-e lateral aspect of plantar region Answer 1: According to dermatology referral there was Swelling around the ulcer it may also be suggestive of mycetoma so dermatology people can't tell if ulcer heals or not if they have done biopsy at ulcer region so they are not ready for aggravating it and have taken biopsy from area below the shin of tibia  Question 2: What is wallerian degeneration and how is it related to infective or any other inflammatory injury including trauma?  How are neurodegenerative disorders different in terms of their neuronal degen
Read more

ICU Bed 1

Image
 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. Thursday,March 10th A 24year old male came with decreased urine output ,sob,pedal edema B.Sushma ,9th semester Roll no.154 March 10th,2022 A CASE DISCUSSION ON DECREASED URINE OUTPUT,SOB,PEDAL EDEMA I've 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 a diagnosis and treatment pla
Read more

51 year old male with foot drop

Image
 September 22th ,2022 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. 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 a diagnosis and treatment plan.   51yr old male patient came with  chief complaints  of    C/o Swelling in the left foot since past 3years C/o Progressive loss of sensation in the left foot since 3years C/o Ulcer in plantar aspect of left foot from past 11months HOPI:  The patient was appa
Read more