General medicine case discussions.

70YR OLD WITH ALTERED SENSORIUM

13/9/21

A 70 year old female  Came to casuality with complaints of fever since 10 days and generalized weakness(Patient stopped going to work)-Patient was active and does her regular activities

History of present illness:-

C/0 fever since 10 days,high grade,intermittent, not associated with chills and rigors

Patient went to local rmp and took medication for fever,but still fever was persistent,yesterday evening Patient went to local hospital and one pint of NS was given and sent home,yesterday night pt became drowsy and not responding to commands 

so today morning pt visited local Hospital and few investigations were done and referred here for further evaluation 

On presentation to casuality, pt was drowsy(Gcs-e3,v1,m4) and had 2 episodes of absence seizures. 

Arousable  on deep painful stimulus 

No h/oheadache,involuntary movements,head trauma or weakness

No h/0 cough,cold, pedal edema, SOB,pain abdomen,loose stools,vomitings

Past history:

H/o previous admission 6 years ago due to ?Anemia

No h/o HTN, tb,asthma,CAD,cva,epilepsy 

Personal history:

Diet:mixed

Appetite:lost

Bowel:regular

Decreased urine output since 2 days

Non smoker, alcohol(occasionally)

General examination:

Patient is comatose ,GCS-E3V1M4 

Pallor+,no cyanosis, clubbing, lymphadenopathy and pedal edema

Vitals:

Pr-113bpm

Bp-80/50mmhg

Rr-36cpm

Spo2-95%@RA

Grbs-117mg/dl

Systemic examination:

Cvs-s1,s2+ No murmrs

Rs-B/l rhonchi ++

Dyspnoea+

P/a:

Non tender,no palpable mass

Cns:

Gcs-E3v1m4,stuporous

Pt moulds all 4 limbs on painfull stimulus

Power-couldnt be elicited

Provisional diagnosis:

Hyponatremia

Altered sensorium under evaluation (?septic encephalopathy)   

(?encephalitis )

?Viral pneumonia 

Pre renal AkI

Hypokalemia under evaluation ,type 2 Respiratory failure 

Old infract In  left frontal lobe

Investigations:

CXR

ABG 14/9/21;12:19AM

ABG 14/9/21 ;7:00AM

LFT

Tb-1.29

Db-0.30

Ast-65

Alt-34

Alp-353

Tp-4.7

                            14/9/21

S.urea-102

S.creat-1.9           2.0

RBS:-82

Serum electrolytes

Na-139

K+-4.1

Cl-102

                                14/9/21

RFT(15/9/21)

Hemogram

Hb-9.3

Tlc-16600

Plt-2.42

14/9/21

CSF ANALYSIS

DENGUE NS1:- negative

2D echo

On 16-9-21:

Her sensorium has improved 

She is responding when questioning but confused  

PR - 100 cpm 

BP - 100/70mmhg

RR  - 25cpm

Spo2 - 98% on 15L of oxyfen

Temp - 101 F

Stool - passed stool

I/o - 4700/2000ml

CNS -

GCS - E4V4M4 

Tone          Right    Left

UL             increased 

LL              increased 

Power 

UL   - 4/5    4/5

LL -    3/5    3/5 

Reflex

B    +        2+

T   3+         3+

S    2+        3+

K     +          + 

A     -           -

P   Extensors bilaterally 

Cvs - S1,S2+

Lungs- BAE+

Inspiratory crepts in bilateral inspiratory IAA, ISA

Per Abdomen -

Soft 

Bowel sounds +

A- 

CSF showed 5 cells with 100 % Lymphocytes 

Her csf glucose level was 40mg/dl

Serum glucose level - 82

  Altered sensorium under evaluation 

? Septic encephalitis 

? Encephalopathy 

?Bilateral lower lobe pneumonia

Prerenal AKI

Old infarct in left frontal lobe 

P - 

1. Head end elevation

2. Oxygen supplementation 

3. IV fluids NS, RL @100ml/hour 

4. Inj Pantop 40mg IV /OD

5. Inj Zofer 4mg/IV/TID

6. Inj Piptaz 2.25g/IV/TID - Day 3

7.Tab Dolo 650mg SOS

On 17-9-21:

She has been having temperature spikes 

Her sensorium has improved 

She is responding when questioning but slightly confused  

PR - 90 cpm 

BP - 130/80mmhg

RR  - 20cpm

Spo2 - 98% on 15L of oxyfen

Temp - 101 F

Stool - passed stool yesterday 

I/o - 1200/1350ml

CNS -

GCS - E4V4M4 

Tone          Right    Left

UL             increased 

LL              increased 

Power 

UL   - 4/5    4/5

LL -    3/5    3/5 

Reflex

B    +        2+

T   3+         3+

S    2+        3+

K     -          -

A     -           -

P   Extensors bilaterally 

Cvs - S1,S2+

Lungs- BAE+

Inspiratory crepts in bilateral inspiratory IAA, ISA

Per Abdomen -

Soft 

Bowel sounds +

A- 

Patient's sensorium has improved post admission but she has been getting  fever spikes 

  Altered sensorium under evaluation 

? Septic encephalitis 

? Encephalopathy 

?Bilateral lower lobe pneumonia

Prerenal AKI

Old infarct in left frontal lobe 

P - 

1. Head end elevation

2. Oxygen supplementation 

3. IV fluids NS, RL @100ml/hour 

4. Inj Pantop 40mg IV /OD

5. Inj Zofer 4mg/IV/TID

6. Inj Piptaz 2.25g/IV/TID - Day 4

7.Tab Dolo 650mg SOS

8. Inj Levipil 500mg IV BD

9. Inj Doxycycline 100mg IV BD Day 4

On 19-9-21:

She has been having temperature spikes 

Her sensorium has improved 

She is responding when questioning and involving in conversations. 

PR - 88 cpm 

BP - 120/80mmhg

RR  - 20cpm

Spo2 - 98% on 15L of oxyfen

Temp - 101 F

Stool - passed stool yesterday 

I/o - 1200/1350ml

CNS -

GCS - E4V4M4 

Tone          Right    Left

UL             increased 

LL              increased 

Power 

UL   - 4/5    4/5

LL -    3/5    3/5 

Reflex

B    +        2+

T   3+         3+

S    2+        3+

K     -          -

A     -           -

P   Extensors bilaterally 

Cvs - S1,S2+

Lungs- BAE+

Inspiratory crepts in bilateral inspiratory IAA, ISA

Per Abdomen -

Soft 

Bowel sounds +

A- 

Patient's sensorium has improved post admission but she has been getting  fever spikes 

  Altered sensorium under evaluation 

? Septic encephalitis 

? Encephalopathy 

?Bilateral lower lobe pneumonia

Prerenal AKI

Old infarct in left frontal lobe 

P - 

1. Head end elevation

2. 2. Oxygen supplementation 

3. 3. IV fluids NS, RL @100ml/hour 

4. 4. Inj Pantop 40mg IV /OD

5. 5. Inj Zofer 4mg/IV/TID

6. 6. Inj Piptaz 2.25g/IV/TID - Day 4

7. 7.Tab Dolo 650mg SOS

8. Tab. Levipil 500mg po bd

9. 9. Inj Doxycycline 100mg IV BD Day 4