75 YEAR OLD MALE WITH ALTERED SENSORIUM

GENERAL MEDICINE E LOG BOOK

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's 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 inputs on the comment

75 YEAR OLD MALE WITH ALTERED SENSORIUM





75 yr old male patient came to the casuality at 9:30 am on 7/11/21 with c/o altered sensorium since yesterday night. 


Patient has 3 sons, is a farmer by occupation, stopped going to work since 3 years due to old age.

He was able to perform all his daily activities on his own.


Pt was apparently asymptomatic till yesterday evening, had dinner and went to sleep. Around 12 am pt suddenly made noises ( like snoring ) and had involuntary movements for 2 mins. From then the patient is unconscious and not responding ( sudden onset )

No h/o tongue bite, no involuntary micturition.

No previous history of seizures.

No previous history of fever and patient was active till yesterday.


Immediately pt was  taken to hospital in Nalgonda and was referred here.


No H/o vomiting , headache 


K/c/o DM since 10 years (on medication)

Not a k/c/o HTN, CAD, CVA, Asthma


Personal history:

Diet- mixed 

Sleep- adequate 

Appetite- normal

Bowel and bladder movements- regular 

Addictions- 

H/o cigarette smoking for 15 years. Stopped 3 years ago 

H/o occasional alcohol intake. Stopped 3 years ago.


Vitals:

Temperature- 102.9 F

BP- 140/80 mmhg

PR- 111 beats / min

RR- 20 cpm

Spo2- 92 % @ 14 L O2

GRBS- 329 mg/dl


O/E

No signs of pallor, icterus, cyanosis clubbing, edema, lymphadenopathy.

No malnutrition/dehydration 


CVS - S1 S2 +. No murmurs 

RS- BAE+ 

Barrel shaped chest +

B/L crepts + in all lung fields

P/A- scaphoid, soft, non tender 

No organomegaly 





CNS- 

Level of consciousness- coma

GCS E1V1M1

Pupils mid dilated. Not reacting to light 

Gag+

neck stiffness +

 Reflexes.          Rt.    Lt 

 Biceps.             2+.  2+

 Triceps.            2+.  2+

 Supinator.        1+.   1+

 Knee.                2+.  2+

 Ankle.               1+.   1+ 

 Plantar.  Withdrawing  mute 


Provisional diagnosis:

Altered sensorium under evaluation 

Sepsis secondary to ? Aspiration pneumonitis

? Old CVA 

COPD

K/c/o Diabetes Mellitus since 10 years 


Investigations:

Hb-13.8

TLC-10,800

PLC-3,00,000

 

PT- 17

INR- 1.2

APTT- 33

Blood group - A +


UKB- negative 

Alb- 2+

Sug- trace 

PC- 4-6

EC- 2-4


ABG- 

PH- 7.314

PCO2-27.9

PO2-47.1

HCO3- 13.8


Urea-55

Creat- 1.8

Uric acid- 7.0

Ca- 9.5

Po4- 4.0

Na- 141 

K- 3.7

Cl- 102


RBS- 332 mg/dl

HbA1c- 7.2%


HIV, HbsAg, HCV- negative 

RAT for covid 19- negative 


ECG




CT BRAIN:

Hypodensity of bilateral cerebellar hemispheres and brain stem 





X ray chest:

B/L consolidation of lungs ( lt > rt )






Treatment 

IVF- NS, RL @ 75 ml/ hr

Inj piptaz  4.5 g IV STAT Followed by 2.25 g IV QID

Inj Neomol 1 g IV SOS if temp > 101F

Inj PAN 40 mg IV/ OD

Inj Zofer 4 mg IV/TID

Inj Optinueron 1 amp in 100 ml NS IV/OD

RT- feeds 2nd hourly 

3 scoops protein powder+ 150 ml milk

Oral suctioning -3rd hourly 

Inj Midaz 0.02 - 0.1 mg/kg/hr 


Pt was intubated I/v/o low GCS and falling Spo2.

ACMV mode:

Fio2- 100

PEEP- 6

vT- 450

RR- 14


Post intubation :


GCS- E1 VT M1

Dolls eye- negative 


ABG- 

PH- 7.235

PCO2-41.3

PO2-292

HCO3- 16.7


Post intubation X-ray


Patient is comatosed ,also under sedation with midaz .

On mechanical ventilation - ACMV - VC mode - 

RR-14/ min

Fio2-80% 

VT-400 ml 

PEEP -7 


O-Afebrile 

GCS -E1VTM1

 Right eye -mature cataract 

Left eye pupils - reacting to light + 

PR-96/min 

RR-21/ min 

BP-110/80 mmHg 

GRBS -222 mg/dl 

RS - BAE + , bilateral infraxillary fine crepts + 

Barrel shaped chest 


CVS - S1,S2 heard 

CNS - comatosed 

           No response to deep painful stimuli.

Dolls eye absent 

Gag reflex + 

Reflex - Rt.        Lft

B-        2+.          2+

T-.        2+.          2+ 

S.        +1.          +1

K          +2.         +2

A.         +1.          +1

Pl.        W.            Mute 


Mrng ABG - severe metabolic acidosis - 

PH -7.1 with HcO3-10.3 

HIGH ANION GAP -28


LP was done yesterday - 

With counts -10 cells , Lymphocytes ,

Sugars -198 

Protein -90 - increased 

? Viral meningitis



A- Altered sensorium under evalation -? Viral meningitis 

High Anion gap metabolic acidosis 

Renal failure - ? AKI 

Known Diabetic since 10 years 


Treatment - 

1- Iv fluids 

2- Nebulisation with duolin and Budecort 

3- GRBs monitoring and insulin according to sugars 

4- Inj .Piptaz 2.25gm / IV / QID




Day 3:


Patient is comatosed ,

On mechanical ventilation - ACMV - VC mode - 

RR-25/ min

Fio2-80% 

VT-400 ml 

PEEP -7 


O-febrile- temp-104 F 

Fever spikes + 

 

GCS -E1VTM1

 Right eye -mature cataract 

Left eye pupils - reacting to light + 

PR-124 /min 

RR-24/ min 

BP-170/90 mmHg 

I/O- 5400/2350 ml 


GRBS -254 mg/dl 

RS - BAE + , bilateral infraxillary fine crepts + 

Barrel shaped chest 


CVS - S1,S2 heard 

CNS - comatosed 

           No response to deep painful stimuli.

Dolls eye absent 

Gag reflex + 

Reflex - Rt.        Lft

B-        2+.          2+

T-.        2+.          2+ 

S.        +1.          +1

K          +2.         +2

A.         +1.          +1

Pl.        W.            Mute 


Mrng ABG - compensated metabolic acidosis 


A- Altered sensorium under evalation -Secondary to PCA stroke( cerebellum and brain stem )  

 CKD 

- sepsis -? Aspiration pneumonia 


K/c/o diabetes since 10 years 


Treatment - 

1- Iv fluids 

2- Nebulisation with duolin and Budecort 

3- GRBs monitoring and insulin according to sugars 

4- Inj .Monocef 2gm/IV/BD .


Day 4:


S: 

Fever spikes+


O:

E1VTM1

Temp- 101.1F

BP-160/100 mmhg

PR- 117 bpm, regular 

CVS- S1 S2+ no murmurs 

RS- NVBS + decreased breath sounds B/l ISA

I/O- 3900/2100 ml

RR- 21 cpm

Spo2- 98% with fio2 50%


SIMV MODE:

fio2- 50%

PEEP- 5 cm H2O

VT- 420 ml 


CNS


 Reflexes.          Rt.    Lt 

 Biceps.             1+.  1+

 Triceps.            -      -

 Supinator.        -      -

 Knee.                -      -

 Ankle.               -      -

 Plantar.          Mute mute 


Corneal and conjunctival reflexes absent 

Dolls eye- absent 

Gag- absent 


Hb-12.1

TLC-13600

Plc-1.40 


Urea -64

Creat-1.6

Na- 147

K-3.7

Cl- 103

CA- 8.3

P- 2


TB-1.12

DB-0.18

AST-122

ALT-59

TP-4.9

Alb- 2.8

A/G-1.39


A:

Hypodensity in b/l cerebellar and brainstorm 

? Viral meningitis 

? AKI secondary to sepsis ? Aspiration pneumonia 

? Consolidation 

With grade I bed sore 


P:

IVF

Nebulisation with duolin and budecort

Inj Neomol  IV if  temp> 101F

Inj Optineuron 

Inj pantop 40 mg IV/OD

inj Ceftrioxone  2 gm IV/OD

Inj HAI 40 IU in 39 ml NS

Tab Amlong 5 mg RT OD

RT feeds 2nd hourly

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