64 M Altered sensorium secondary to meningoencephalitis (? TB ) - Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's - Prerenal AKI - B/L fixed flexion deformity since 2 yrs

 

A 64 YR OLD WHO IS UNABLE TO TALK SINCE 1 DAY 

December 28, 2022
28/12/2022



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 inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs  on comment box is welcome.

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 diagnosis and treatment plan

CASE :

 CHIEF COMPLAINTS :

Patient came to casuality with chief complaints of 
- unable to talk since 1 day 
- hiccups since 7 days
-  bowel and bladder incontinence, loss of appetite  since 3 days 
- loose stools 5 days back relieved on medication 
- fever 4 days back 

History of present illness :- 

Patient was apparently asymptomatic 7 days back , he then developed hiccups , loss of speech

-  5 days back he developed diarrhoea  5 episodes/ day , for one day which was relieved on medication 

-loss of appetite since 3 days , since one day he is unable to talk
 
- No H/O SOB , cough , palpitations
- No H/O loss of consciousness , giddiness , involuntary passage of urine and stools .

Past history :- 
- h/o panic attack one month back secondary to family issues 

- K/C/O DM2 since 2 yrs , on medication , 
-tab Metformin OD , tab Glimiperide OD

- Not a K/C/O HTN, TB, Asthma, epilepsy, CAD, CVD

Personal History :- 

Appetite - lost

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements - incontinence 

Addictions: Occasional alcoholic ( during functions ) , tobacco chewing occasionally 

Allergies : No allergies  

Family history :- not significant 

GENERAL EXAMINATION: 


Patient is conscious ,incoherent , uncooperative
 Moderately Built and Moderately Nourished .

Pallor : present 
Icterus : absent 
Cyanosis: absent 
Clubbing : absent 
Lymphadenopathy : absent 
Edema : absent
 





His vitals :- 

Temp: Afebrile 
BP : 100 / 50 mmHg 
PR : 120 bpm 
RR : 16 cpm 
SPO2 : 98 % at RA
GRBS : 193 mg/dl 
Qaa
SYSTEMIC EXAMINATION: 

CNS examination :-
State of consciousness : conscious 
Speech : incoherent 
Kernigs sign :- positive

Sensory system :- 

Pain - Normal 
Touch- fine touch - normal
      crude touch - normal
Temp - normal
Vibration - normal
Joint position - normal

Cranial nerves : intact


CNS :-
                    Right.                   Left
Tone :-   UL    hyper                 hyper 
               LL.   Hyper                hyper 

Power :- UL and LL     moving all four limbs in response to pain     
                     

Reflexes :-
Biceps           + +
Tricep s     + +
Supinator     + +
Knee      + +
Ankle. ++
Flexor. Plantar. Plantar 

Finger nose in coordination - no 
Heel knee in coordination - no

CVS : S1 S2 + ,no murmurs ,no thrills 

Respiratory System : decreased air entry on left side . Diffuse crepts on left side. Position of trachea - central.

Per abdominal examination:- 

Soft , non tender , no signs of hi organomegaly 

Investigations:- 
ECG 

Chest x ray pa view ;- 

USG abdomen:- 

MRI brain :- 




hemogram 
RBS
LFT

serum creatinine 

serum electrolytes :- 
provisional diagnosis:- 

CVA , hyponatremia 

Management:-
1) IVF 0.9 %NS IV @ 50 ml / hr 
2) Inj , 1 amp Optineuron in 500 ml NS IV /OD 
3) tab Ecosprin AV 75/10 RT / OD / HS
4) GRBS monitoring 6 th hrly 
5) Inj Thiamine 200 mg IV/BD in 100 ml NS 
SOAP NOTES 
 2/1 /2023
ICU
Bed 6
Day 5  


S: 
Pt in altered sensorium  


O : 
Patient is stuporous 
BP :110/70 mm hg 
PR :- 107 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 146 mg/dl
I/O : 2100/1100 ml 

CNS :- GCS : E4V1M1
                        Right. Left
Tone :- UL hypo hypo
             LL hypo hypo

Power :- UL   : not moving even with pain LL : 
 Reflexes:-not elicited 
Brain stem reflexes :-
B/L corneal + ,conjuctival + , pupillary + , 
Doll's eye : absent on left 
Gag :+ 
Plantar : left - , right - increased  

CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  crepts +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 

- Left sided pneumonia ( ?TB ) 


P:-
) IVF 0.9 %NS IV @ 75 ml / hr 
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
4) Inj . Dexa 6 mg IV / TID 
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS 
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 

Investigations :-



CBNAAT OF CSF : NEGATIVE 

frequent position change

 9/1 /2023


S: 
No fresh complaints 
No bed sores
No fever spikes
Stools not passed
c/o hiccups

O : 
Patient is conscious , oriented to person and place 
BP :120/70 mm hg 
PR :- 100 bpm
RR : 20cpm 
Temp : 97.2 F 
Spo2 : 98 % at RA 
GRBS 84mg/dl
I/O : 2100/1350 ml 

CNS :- GCS : E4V5M6-15/15

                   Left Right.                                
Tone :- UL N Hypo      
             LL N Hypo     

Power :- Left Right
       UL. 3/5 0/5
        LL. 2/5 0/5

Reflexes:- not elicited 
CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  NVBS +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's 
- Prerenal AKI (resolving)
- B/L fixed flexion deformity since 2 yrs 
- Hyponatremia ? SIADH



P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr 
- Nebulization with ipravent - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg RT/OD 
- syp lactulose 15 ml RT / BD 
- Inj .Thiamine 100 mg IV/BD in 100 ml NS 
- ATT therapy RT/OD FDL : 3 tabs/ day 
     Tab Isoniazid 75mg
     Tab Rifampicin 150mg
     Tab pyrazinamide 400mg
     Tab ethambutol 275mg
 - RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 
- Tab Tolvaptan 30mg PO/OD 
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change



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