A 75 YEARS OLD MALE WITH ALTERED SENSORIUM

MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his 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 those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CASE 

A 75 year old male came with complaints of 

 fever since 10 days 

altered sensorium since 5 days  

HOPI:

Patient was apparently asymptomatic 10 days back and then developed fever which was high grade not associated with chills and rigor. Then he developed altered sensorium since 5 days he was not able to recognise his family members.

PAST HISTORY:

Not a K/C/O DM, HTN, TB,EPILEPSY, ASTHMA

Has hypo-pigmented patches on b/l lower limbs and b/l nipples since 6 years using herbal medication regularly, itching is present.

PERSONAL HISTORY:

He is Married

He consumes 

Mixed diet 

sleep is adequate 

Appetite normal

bowel and bladder movements are regular

He Consumes Alcohol twice a week (90ml) since 50 years presently abstinent since 15 days 

He smokes beedi 1-2 packs/day since 55 years 

FAMILY HISTORY: no similar complaints in the family.

DAILY ROUTINE: Wakes up early in the morning around 5:00am and then goes to the farm, comes back home at 10:00am has breakfast (Tea and bread or some tiffin), from 10:00am to 6:00pm he stays home takes rest and does house chores. Takes his meals on time (3 meals/day).

Sleeps at 10:00pm and the routine continues.

CLINICAL IMAGES:

GENERAL EXAMINATION:

Patient is conscious ,non-cooperative, not oriented to time, place and person.

Thinly built and nourished.

VITALS:

BP: 120/70mmhg

PR: 90bpm

RR: 20cpm

Temp: 100f

SYSTEMIC EXAMINATION:

RS:

Inspection : barrel shape 

Decreased breath sounds on right side 

Diffuse expiratory wheeze

CVS: s1,s2 no added sounds

P/A: not tender

Pt is altered

GCS - E3V1M6 

Speech - making incomprensible sounds 

Pupils:NSRL

Motor 

Power : Not moving his left upper limb and lower limb as actively as right side

Tone : Normal

Reflexes : B T S A K P 

           R: - - - - - Flexion 

           L : - - - - - Flexion 

Neck rigidity : Present 

Kerning's : Positive 

Brudzski : Negative

PROVISIONAL DIAGNOSIS: ALTERED SENSORIUM UNDER EVALUATION 

INVESTIGATIONS:

On Day1 

ABG: Day 1 at 10:43pm

ABG: Day 1 at 11:51pm

3/09/22

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.INJ.IVF DNS 50ml/hr

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.MONITOR VITALS EVERY 6th hrly

7.GRBS MONITORING EVERY 4th 

Day 2

S: fever since 10 days and altered sensorium since 5 days

Presently altered sensorium 

O: pt is conscious,uncooperative,not oriented to time,place and person.

BP: 120/70mmhg

PR: 90bpm

RR: 20cpm

Temp: 98.6f

SYSTEMIC EXAMINATION:

RS:

Inspection : barrel shape 

Decreased breath sounds on right side 

Diffuse expiratory wheeze

CVS: s1,s2 no added sounds

P/A: not tender

CNS:

Pt is altered

GCS - E3V1M6 

Speech - making incomprensible sounds 

Motor 

Power : Not moving his left upper limb and lower limb as actively as right side

Tone : Normal

Reflexes : B T S A K P 

           R: - - - - - Flexion 

           L : - - - - - Flexion 

Neck rigidity : Present 

Kerning's : Positive 

Brudzski : Negative

A: ?Altered sensorium under evaluation

?Alcohol withdrawal syndrome 

P:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.INJ.IVF DNS 50ml/hr

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.MONITOR VITALS EVERY 6th hrly

7.GRBS MONITORING EVERY 4th hrly

INVESTIGATIONS:

ABG: Day 2 at 6:17 am

ABG: Day 2 at 4:46pm

Plan: Patient intubated on ACMV VC MODE as he was hypoxic Post Intubation Ventilator Settings : 

RR - 16

Fio2 - 40

PEEP - 5 

TV - 400

Post Intubation Vitals :

Pupils - B/L Fixed Pin point Pupils 

BP - 100/70mmHg 

PR - 116/Min 

RR - 22/Min 

Spo2 - 100%

Midaz Infusio - 5ml/hr

Atracurium Infusion - 10ml/hr

ABG:Day 2 at 9:50pm

Day 3

S:pt is on mechanical ventilator and sedation 

O: pt on SIMV VC mode

RR TOTAL: 29

RR:20

Fio2:30%

PEEP: 5 cm of H2O

TV:400

VITALS:

BP: 110/70mmhg

PR: 82bpm

RR: 16cpm

Temp: 98.5f

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender

A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly 

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.Inj.NEOMOL IV if TEMP>102f sos

7.GRBS MONITORING EVERY 4th hrly

8.Inj.MIDAZ 5ml/hr

9.Tab. Azithromycin 500mg PO/OD

Day 3 At 9:30 am 

Pt was able to breath on its own so the changes were done to SIMV -VC Mode 

RR Total - 29

RR - 16

Fio2 - 30 

PEEP - 5 

VT - 400

Vitals - 

BP - 100/80

RR - 38/min

HR - 108/min

Spo2 - 97

ABG: Day 3 at 12:20pm

ABG: Day 3 at 9:20pm

On Day 4

S:pt is on mechanical ventilator and sedation 

O: pt on SIMV VC mode

RR TOTAL: 29

RR:20

Fio2:30%

PEEP: 5 cm of H2O

TV:400

VITALS:

BP: 110/70mmhg

PR: 97bpm

RR: 16cpm

Temp: 97.6f

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender

A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly 

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD

6.Inj.NEOMOL IV if TEMP>102f sos

7.GRBS MONITORING EVERY 4th hrly

Abg day 4 at 9am

CULTURE REPORT:

Abg day 4 at 10:36pm

Abg day 5 at 6:30 am

Day 5

S:pt is on mechanical ventilator and sedation 

O: pt on SIMV VC mode

RR TOTAL: 34

RR:16

Fio2:21%

PEEP: 5 cm of H2O

TV:400

VITALS:

BP: 130/70mmhg

PR: 122bpm

RR: 20cpm

Temp: 100.8f

SpO2: 97%

GRBS: 327 mg/dl

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender

CNS:

Doll’s eye reflex +

Pt is unresponsive

GCS - E1VTM1

Pupils:B/L equal constricted and reacting to light.

                          R L

Corneal + +

Conjunctival. +. +

Tone : Hypotonia

Reflexes : B T S A K P 

           R: - - - - - Flexion 

           L : - + - - - Flexion

A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

TREATMENT:

1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD

2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly 

3.INJ.PANTOP 40mg IV/OD

4.INJ.ZOFER 4mg IV/SOS

5.INJ.Dexamethasone 4mg BD

6.Inj.NEOMOL IV if TEMP>102f sos

7.GRBS MONITORING EVERY 4th hrly

8.INJ.Clexane 40mg S/C OD

9.Tab. Azithromycin 500mg PO/OD

10.NEB BUDECORT 12th hrly DUOLINE 8th hourly 

11.Monitor vitals

Abg day 5 at 3pm

Day 6

S:pt removed from ventilation and was put on T. Piece since today morning 7.30 am 

O:

Pt conscious 

GCS:E4VTM4

spontaneous eye opening + 

Spontaneous breathing +

VITALS:

BP: 120/70mmhg

PR: 137bpm

RR: 30cpm

Temp: 101.3f

SpO2: 98%

GRBS: 197 mg/dl at 8:00am

SYSTEMIC EXAMINATION:

CVS: s1,s2 no added sounds

P/A: not tender,Soft

A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.

P:

Plan to extubate

Abg day 6 at 6:30am

Abg day 6 at 9:30am

Abg trends