Case 23 - A 70 yr old male with altered sensorium

70 year old male farmer by occupation came to the casualty with sudden onset of a aphasia since yesterday night .
patient was apparently asymptomatic till yesterday then he woke up from bed at 11 p.m. to go to washroom and fell from bed and his attenders
 observed aphasia (sudden onset) and he is unable to wake up from the floor.
 no history of trauma to the head, no involuntary micturition and defaecation.


H/O fever 5 days back not associated with chills and rigors and not associated with nausea and vomiting,took treatment from local RMP.
No H/o pedal edem,SOB,burning micturition.
 H/o tingling sensation of bilateral upper limb and lower limb since 1 month 
 
not a known case of asthma ,TB epilepsy 

 known case of diabetes since one year and hypertension since one year and on irregular medication 
 alcoholic occasionally(last drink 1week back) and smoking (1chutta/day) since 45yrs.

Personal history : 
Married 
Diet - mixed 
Appetite - normal
Sleep - adequate 
Bowel movements : regular .
Bladder movements : regular


O/E:
Pt is conscious,non coherent,non cooperative

Vitals: 
Temp : 98.6F
BP: 140/90
PR: 114
RR: 28
Spo2: 99% on 6lit of 02
Grbs:

CVS: S1,S2 heard 
RS: BAE +,NVBS 

P/A: soft , NonTender
Bowel sounds heard
CNS : pt is conscious,non coherent,non cooperative

GCS -9/15
  neck stiffness present,kernigs sign is negative.


MOTOR SYSTEM 

                      R L 

TONE UL NORMAL NORMAL 

            LL NORMAL NORMAL

POWER UL 3/5 3/5 

                LL 3/5 3/5 



REFLEXES 

           B T S K A

R - - - - -

L - - - - -
Plantar flexion +.

 Dia:Altered sensorium under evaluation secondary to ? meningoencephalitis (?dengue , ?leptospirosis)
Acute infarct in caudate nucleus 
?Prerenal AKI with direct hyperbilirubinemia(secondary to sepsis)
K/c/o DM,HTN since 1yr

HFMEF secondary to ? old anterior septal MI, inferior wall MI (CAD),(EF:45per)
Rx:1.IVF(NS,RL)@ 75 ml/hr
2.INJ CEFTRIAXONE 2G/IV/BD 
3.INJ VANCOMYCIN 1G/IV/STAT  F/B  IV/BD.
4.INJ DEX 8MG/BD.
5.NEB WITH BUDECORT AND IPRAVENT(STAT) &@ 6LIT OF O2/MIN
6.INJ PAN 40MG/OD.
7.INJ ZOFER 4MG/TID.
8.RT FEEDS(100ML OF WATER,100ML OF MILK WITH PROTEIN POWDER) 4TH HRLY 
9.TAB ECOSPORIN-AV(75/40MG)/OD 
10.INJ THIAMINE 100MG/TID IN 100ML NS .
11.SYRUP LACTULOSE 15ML/BD/PO
12.INJ DOXYCYCLINE 100ML/BD(DILUTE IN 100ML NS.)
13.INJ HAI  S/C ACCORDING TO GRBS(8AM-2PM-8PM).
14.INJ NEOMOL 1G/1V/SOS.
15.BP,PR,SPO2 HRLY MONITORING,GRBS 6HRLY MONITORING,TEM 4HRLY MONITORING.








 

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