64years old male patient presented with unable to speak

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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

CHIEF COMPLIANTS :

  -Unable to speak since 4 days .Hiccup since 7days

  -loose stools, loss of appetite since 3 days

  -fever 4 days back 

 History of presenting illness:

patient is apparently asymptomatic 1and half year back then he developed jaundice for this treatment is given local hospital patient was recoved .1 week back then he developed diarrhoea -5 episodes/day for 1 day which relieved on medical treatment .since  25/12 he is unable to talk.

History of cough present since 10days .

PAST HISTORY :

h/o panic attack one month back secondary to family issues 

  -DM2 since 6 yrs , on medication , 

-tab Metformin OD , tab Glimiperide OD

 -NO HISTORY OF 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 daily 

Allergies : No allergies 

Family history: patient daughter is diagnosed as tb 7years back and treated.

Patient mother is diagnosed as tb 5years back and treated .

GENERAL EXAMINATION :

Patient is conscious ,incoherent , uncooperative

 Moderately Built and Moderately Nourished .

Pallor : present 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent

 Vitals :- 

Temp: Afebrile 

BP : 100 / 50 mmHg 

PR : 120 bpm 

RR : 16 cpm 

SPO2 : 98 % at RA

GRBS : 193 mg/dl 

SYSTEMIC EXAMINATION: 

CNS examination :-

State of consciousness : conscious 

Speech : incoherent 

Kernigs sign :- negative

Sensory system :- 

Pain - Normal 

Touch- fine touch - normal

      crude touch - normal

Temp - normal

Cranial nerves : intact

CNS :-

 

   

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 . Position of trachea - central.

Per abdominal examination:- 

Soft , non tender , no signs of organomegaly

Investigations:-

ECG  

chest x ray :

CSF analysis:

pectus excavatum :

COMPLETE URINE EXAMINATION

Colour - pale yellow

Appearance - clear

Reaction - acidic

Specific gravity - 1.010

Albumin -nil

Sugar -nil

Bile salts - nil

Bile pigments- nil

Pus cells - 2-3cells(normal 0-5/HPF)

Epithelial cells- 2-3 cells(normal 0-5HPF)

RBC -nil (normal 0-5/HPF)

Crystals-nil

Casts-nil

Amorphous deposits-absent

BLOOD UREA -124mg/dl(normal 17-50mg/dl)

APTT

  

APTT TEST- 31sec(normal 24- 33sec)

Bleeding and clotting time

Bleeding time- 2min 30sec(normal2 -7 min)

Clotting time- 5min (normal 1- 9min)

PROTHROMBIN TIME - 15sec ( normal 10 -16 sec)

  DIAGNOSIS :

    Altered sensorium secondary to      

meningoencephalitis 

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

29/12/2022 at 12 pm

on 30/12/2022

icu

bed 6

day 2 

unit 3 

dr.nikitha (sr )

dr.vamshi krishna ( pg 3 )

dr. nishitha ( pg 2 ) 

dr.govardhini reddy ( pg 1 )

dr. meghana ( intern )

dr. tejarshini ( intern) 

s: 

no fever spikes 

stools passed 

 

o : 

patient is drowsy but arousable 

bp :120/80 mm hg 

pr :- 102 bpm

rr : 17 cpm 

temp : 98 f 

spo2 : 98 % at ra 

grbs :- 275 mg/dl

i/o : 1500/900 ml 

cns :- gcs : e3v4m6

cvs : s1 , s2 heard, no murmurs  

rs : bae + , decreased air entry on left side , crepts +

p/a:- soft , non tender 

a :- 

- altered sensorium secondary to meningoencephalitis (? tb ) 

- left sided pneumonia ( ?tb ) 

p :

1) ivf 0.9 %ns iv @ 75 ml / hr 

2) nebulization with duolin - 8th hrly , budecort - 12 th hrly

3) inj , 1 amp optineuron in 500 ml ns iv /od 

4) inj .thiamine 200 mg iv/bd in 100 ml ns 

5) inj .monocef 2 gm iv/bd 

6) inj . clindamycin 600 mg iv / tid

7) inj . dexa 6 mg iv / tid 

8) t.baclofen 10 mg rt/tid

9) att therapy 

10) grbs monitoring 6 th hrly

11) vitals monitoring 6 th hrly

12) temp monitoring 4 th hrly

13) inj h. actrapid insulin sc 

31/12/2022: 

Bed 6

Day 3 

Unit 3 

Dr.Nikitha (SR )

Dr.Vamshi Krishna ( PG 3 )

Dr. Nishitha ( PG 2 ) 

Dr.Govardhini Reddy ( PG 1 )

Dr. Meghana ( intern )

Dr. Tejarshini ( intern) 

S :

Pt in altered sensorium

 

O : 

Patient is drowsy but arousable 

BP :120/80 mm hg 

PR :- 102 bpm

RR : 17 cpm 

Temp : 98 F 

Spo2 : 98 % at RA 

GRBS :- 246 mg/dl

I/O : 2100/1100 ml 

CNS :- GCS : E2V1M4

            Right. Left

Tone :- UL hypo hypo

             LL hypo hypo

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

CVS : S1 , S2 heard, no murmurs  

RS : BAE + , decreased air entry on left side , crepts +

P/A:- soft , non tender 

A :- 

- Altered sensorium secondary to meningoencephalitis (? TB ) 

- Left sided pneumonia ( ?TB ) 

P :

1) IVF 0.9 %NS IV @ 75 ml / hr 

2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly

3) Inj , 1 amp Optineuron in 500 ml NS IV /OD 

4) Inj .Thiamine 200 mg IV/BD in 100 ml NS 

5) Inj .Monocef 2 gm IV/BD 

6) Inj . Clindamycin 600 mg IV / TID

7) Inj . Dexa 6 mg IV / TID 

8) T.Baclofen 10 mg RT/TID

9) ATT therapy 

10) GRBS monitoring 6 th hrly

11) vitals monitoring 6 th hrly

12) Temp monitoring 4 th hrly

13) Inj H. Actrapid insulin SC TID acc to GRBS