case 43 : 21M ALTERED SENSORIUM UNDER EVALUATION

 

Tuesday, September 20, 2022

21 year old male with altered sensorium

thanks Dr. Shishira (intern)
Pt came to casualty in state of altered sensorium with slurring of speech since yesterday

Pt does hotel management and stays alone.

 He was apparently asymptomatic 5 days back. He had fever 5 days back which was high grade, continuous, associated with chills and rigors. No history of cold and cough . He went to local hospital got treated but the fever did not subside.
Later after a day he consumed beer, had biryani.
He had 1 episode of vomiting and loose stools since 3 days. (2 days back), while he was in room suddenly he had involuntary movements of all 4 limbs associated with frothing, uprolling of eyes, post ictal confusion, he bit his lower lip  no tongue bite . He had 1 episode of vomiting at the time of involuntary movement, and loose stools. 
Loose stools, foul smelling. 

Since yesterday afternoon, pt was in altered sensorium , with slurred speech, and deviation of mouth.

He presented to hospital on 19/09/22 and was treated he was sedated at 1am  was sent home at 4:30am . He woke up at 2pm . He had altered sensorium and involuntary movements. 

No c/o weakness of upper limb and lower limb.
No h/o cough, cold, palpitations, syncopal attacks, chest pain

PAST HISTORY 
N/k/c/o - DM, HTN, EPILEPSY,TB , ASTHMA 

FAMILY HISTORY
No significant history 

PERSONAL HISTORY
appetite- normal 
Diet- mixed
Bowel and bladder - normal 
Sleep- regular
Habits - alcohol consumption occasionally,
Smoking 




General examination:
On examination: 
Pt is in altered sensorium
No pallor, Icterus, clubbing, cyanosis lymphadenopathy, edema

VITALS
BP 110/60mmHg
PR 110bpm
Temp. 100°F
CVS S1, S2 +
RS - BAE +, NVBS

CNS EXAMINATION:
NERVOUS SYSTEM EXAMINATION 

a. Conscious
 b. Not Oriented to time, place and person
 c. Speech and language –no aphasia, dysarthria, dysphonia 
d. Memory – immediate-retention and recall, recent and remote - not intact 

MOTOR examination 

Meningeal signs
Kernigs sign +
Brudzinski sign -

Power:
                       Rt.                   Lt
UL                 +4/5.              -4/5
LL.                +4/5.              -4/5


Tone 
UL.                N                        N
LL.                 N.                       N

Hand grip:  100%.                100%


Provisional Diagnosis: MODS (Meningoencephalitis, Hepatitis & Glomerulonephritis) due to ? Systemic Vasculitis associated with ? Rickettsial Spotted Fever ? Viral Hemorrhagic Fever ? HUS/TTP

Investigations
21/09/22
PT 16SEC
INR 1-11 SEC
 Hemogram

Urinary electrolytes


CUE

Urine protein /creatinine ratio





23/09/22 




Treatment 
21/09/22
1)IVF NS , RL @100ML/hr
2)INJ. ZOFER 4MG IV/SOS
3)INJ. THIAMINE 200MG IN 100ML NS/IV/TID
4)STRICT I/O CHARTING
5)BP/PR/RR/SPO2 2nd Hrly.



22/9/22
O/E 
Patient was agitated, talking to self, irritable
BP- 120/90 mmHg
PR - 96bpm
CVS- S1 S2 + 
RS- BAE+ , NO ADDED SOUNDS
P/A- SOFT

A: ALTERED SENSORIUM UNDER EVALUATION 2° TO ? DENGUE ENCEPHALITIS WITH PRE RENAL AKI WITH VIRAL HEPATITIS. 

P 
IVF NS, DNS @70ml/hr
INJ. ZOFER 4mg/IV/SOS
INJ. THIAMINE 2OO mg in 100 ml NS IV/TID
STRICT I/I CHARTING
SYP. DUPHALAC 15ML PO/TID
TAB DOXY 100 mg/ RT/BD




24/09/22
S: agitated, non co-operative 

O: 
Pt concious
Temp : 98.7
BP: 140/90mmHg
PR - 72bpm
CVS S1 S2 + 
RS - BAE+
P/A- soft, tender
GCS- E4V5M6

A: altered sensorium under evaluation 2° dengue encephalitis with pre-renal AKI (resolved)
with viral hepatitis with alcohol withdrawal syndrome with MODS

P:
1) IVF NS,DNS @75 ml/hr
2) INJ.DOXY 100mg/IV/BD
3) INJ. DEXA 8mg/IV /TID 
4) INJ. THIAMINE 200mg in 100ml NS/IV/BD
5) SYP. DUPHALAC 30ml PO/TID
6) STRICT I/O CHARTING
7) BP/PR/SPO2 MONITORING 2ND HRLY. 



25/09/22
ICU bed 4
21year old male 

S: sensorium improved 
Fever spikes+

O: 
Pt concious
Temp : 100.7
BP: 140/90mmHg
PR - 70bpm
CVS S1 S2 + 
RS - BAE+
P/A- soft, tender
GCS- E4V5M6

A: altered sensorium under evaluation 2° ? TTP 
? Viral encephalitis with renal AKI (glomerulonephritis)
with viral hepatitis  with MODS.

P:
1) IVF NS,DNS @75 ml/hr
2) INJ.DOXY 100mg/IV/BD
3) INJ. DEXA 8mg/IV /TID 
4) INJ. THIAMINE 200mg in 100ml NS/IV/BD
5) SYP. DUPHALAC 30ml PO/TID
6) STRICT I/O CHARTING
7) BP/PR/SPO2 MONITORING 2ND HRLY. 


26/9/22

S:Sensorium improved
   No fever spikes

O: Pt is conscious,coherent 
Cooperative 
BP-110/90
Pr-76
Temp-98.1f
CVS-S1S2+
P/A -soft,NT
Spo2-95%

A:ALTERED SENSORIUM UNDER EVALUATION secondary to  ?TTP  with pre-renal AKI(resolved) 
with viral hepatitis with alcohol withdrawal syndrome with MODS


P:Plan for treatment 
1.Plenty of oral fluids
2.INJ DOXY 100mg/IV/BD
3.INJ DEXA 8mg/IV/BD
4.INJ THIAMINE 200mg in 100mlNs/IV/OD
5.SYP DUPHALAC 30ml PO/TID
6.Strict I/O charting


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