case 40 : A 42 Year old male with Altered Sensorium

 

A 42 Year old male with Altered Sensorium

August 16, 2022
thanks Dr. Arushi (intern)

Chief Complain :
A 42 year old male was brought to casuality in a state of altered sensorium with history of fever since 10 days , vomiting since 10 days , generalised weakness and drowsiness since 10 days.

HOPI :
Patient was asymptomatic 1.5 years ago and then developed involuntary movements of upper limb and lower limb associated with uprollong of eyes and for which he was taken to alocal hospital and was diagnosed to be having alcoholic encephalopathy and dyseloctrolytemia for which he was treated conservatively and was discharged in a hemodynamically stable condition. 
From then he was asymptomatic until 10 days ago , when he developed fever which is of low grade and relieved on medication and developed generalised weakness and vomiting 4-5 episodes in a day and the content are food particles and non- bilious and also associated with nausea. C/O generalised weakness and drowsiness since 10 days. With above complains patient visited multiple hospitals and received symptomatic treatment in the past 10 days and came to our hospital on 10/08/2022 for further management .
- No H/O headache , giddiness , seizures 
- No H/O pain abdomen, loose stools 
- No other complains 

Past History 
Not a known case of DM and HTN

Personal History
- Mixed diet
- decreased sleep and appetite 
- chronic alcoholic 

Family History : Not significant 

Vitals at admission :
BP: 60/50
PR: 74bpm
RR: 16cpm
GRBS: 84mg/dL
Systemic examination :
RS: BAE + clear
CVS: S1S2 heard
P/A: soft, non-tender
CNS: Patient is drowsy, but arousable 
E3V4M6
- No signs of meningeal irritation 
- NFND





INVESTIGATIONS :

10/08/2022




11/08/2022




12/08/2022



13/08/2022


S. Creatinine : 0.5mg/dL

Blood Urea :12mg/dL

14/08/2022




15/08/2022 
Morning 
Evening 
16/08/2022
Morning 


 Evening 


17/08/2022

18/08/22
Morning 




19/08/22 
Morning 



Fever Chart 

Plan of care-
 1.IV fluids
0.9%NS@150ml/hr
2.Inj.pantop 40mg iv/OD
3.Inj.zofer 4 mg iv/sos
4.Inj.neomol 100ml iv/sos
(If temp is more than 101 degree F)
5.Inj.thiamine 100mg iv/tid
6.Inj.cetriazone 2Gm iv/bd
7.Inj.Lorazepam2 cc IV (if seizure episode)
8.Inj.Levipil 500mg iv/bd
9.inj.meropenam iv/Bd (day 4)
10.Tab.Dolo650mg po/tid
.Monitor vitals-4rth hourly
  I/O charting

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