A 42 year old male with altered sensorium and fever

 A pt was brought to a hospital with chief complaints of 

altered sensorium since yesterday and fever since yesterday

HOPI;

Patient was apparently asymptomatic 3 years back,then he started sleep taking at night time with shouting in between ,also abuses his wife gets angry for small reasons,used to abuse his coworkers also near work place.

This continued till last Sunday,then patient was taken to Hyderabad(rehabilitation centre) on last Sunday and was admitted there after which he was normal for 4 days and then since Friday started abusing everyone.

From today morning he was in altered sensorium and was drowsy and was brought to a hospital.

Complaints of fever since yesterday which is insidious gradually progressive not associated with chills and rigor.No aggrevating factors and relieved with medication.

PAST H/0:

Not a k/c/o DM,HTN,THYROID,ASTHMA,EPILEPSY.

PERSONAL HISTORY:

Marital status-Married

Occupation- Farmer

Diet: mixed

Appetite: normal

Bowel and bladder : Normal

Addictions:Alcoholic since 20 years(increased intak

e since 10 years

FAMILY HISTORY:

No similar complaints in the family.

GENERAL EXAMINATION:

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

he is drowsy.

Built & nourishment-Moderate

No pallor 

No cyanosis

No icterus

No clubbing

No edema

No lymphadenopathy.

SYATEMIC EXAMINATION:

CVS : 

S1 S2 present

No murmurs

RESPIRATORY SYSTEM;

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard

ABDOMEN:

Shape of abdomen: scaphoid.

Soft, non tender, no organomegaly present.

No rigidity or guarding.

CNS :

Patient is conscious

Speech-normal 

Signs of meningial irritation

Neck stiffness- negative

Kernings sign-negative

Cranial nerves-intact

Motor system:

Power:

            R. L

UL. 5/5. 5/5

LL. 5/5. 5/5

 

Tone:

            R. L

UL. Normal. Normal

LL. Normal normal

Sensory system: normal

Reflexes:

           Knee. Ankle. Biceps. Triceps supinator

Right 2+. 1+. 2+ 1+. 1+

Left. 2+. 1+. 2+ 1+ 1+

Plantar flexion seen.

No cerebellar signs

TREATMENT:

1.IV FLUIDS NS @50ML/HR

2.INJ.THIAMINE 100MG IN 100 ML NS IV/TID

3.INJ.OPTINEURON 1AMP IN 100ML NS I /OD

4.INJ.NEOMOL 1GM IV/SOS

5.TAB.SDOLO 650 MG PO/SOS