A 64 YR OLD MALE WHO IS UNABLE TO TALK SINCE 4 DAY

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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 

  -Hiccups since 7 days

  -loose stools, loss of appetite since 3 days

  -fever 4 days back 

  -cough since 10 days

HISTORY OF PRESENT ILLNESS

patient is apparently asymptomatic 1 week back then he developed diarrhoea -5 episodes/day for 1 day which relieved on medication.Then he developed having hiccups since 7 days and anorexia for 3days.since 25/12/22 he is unable to talk.

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

GENERAL EXAMINATION

Patient is unconscious ,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 :-

HIGHER MENTAL FUNCTIONS

State of consciousness : unconscious 

Speech : incoherent 

Sensory system :- 

Pain - Normal 

Temp - normal

Cranial nerves :  

Not elicited patient not cooperative

CNS 

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 . Crackle sound are heard. Position of trachea - central.

Per abdominal examination:- 

Soft , non tender , no signs of organomegaly

Investigations:-

ECG  

Chest x ray

CSF ANALYSIS

Sugar  51 mg/dl (normal 60-90mg/dl)

Protein 203mg/dl( normal 10- 45mg/dl)

Chloride 121 mmol/L (116-127mmol/l)

CSF CELL COUNT

Colour - colour less

Appearance - slightly cloudy

Total cells - 90 cells /cumm

Lymphocytes -60%

Neutrophils - 40%

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)

FLIXED FLEXION DEFORMITY OF KNEE

PECTUS EXCAVATUM 

MRI BRAIN PLAIN 

DIFFUSE CEREBRAL ATROPHY

BLOOD SUGAR 159mg/dl 

 DIAGNOSIS 

    Altered sensorium secondary to      

meningitis (Tuberculosis?)

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 :-

AMC 

Bed 4 

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 fresh complaints 

O : 

Patient is conscious , non coherent, non cooperative

BP :110/60 mm hg 

PR :- 110 bpm

RR : 16 cpm 

Temp : 98 F 

Spo2 : 98 % at RA 

CVS : S1 , S2 heard, no murmurs  

RS : BAE + , decreased air entry on left side , no wheeze , no crepts

CNS :- 

Reflexes :- right. Left 

Biceps - -

Triceps - -

Supinator - -

Knee -. -

Ankle - -

GCS : E4V1M4

                     Right. Left

Tone :- UL hyper hyper 

             LL hyper hyper 

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

P/A : soft , non tender  

A :- 

- Altered sensorium secondary to meningoencephalitis 

- hyponatremia 

- AIS ( Tiny acute infarct in right temporal lobe ) 

P :

) 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 

6) T.Baclofen 10 mg RT/TID

Lumbar puncture video performed on 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 TID acc to GRBS

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

Follow up : 14/03/23