case 9 : 75F Altered sensorium with motor weakness

 

June 09, 2021 thanks https://rollno52.blogspot.com/2021/06/75-year-old-with-altered-sensorium.html?m=1

75 YEAR OLD WITH ALTERED SENSORIUM

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Chief complaints 

75 year old  Presented in unconscious state with a history of hanging (given by the attendants)which needed immediate intubation. GCS was E1V1M3.

History of presenting illness

1)Chronic complaints of shortness of breath and cough since 10 years

2)intermittent symptoms of pain since 10years

3)1 and half month back complaints of fever and shortness of breath ,was diagnosed with TB. On anti tuberculosis medication since then.

4) No history of orthopnea, pedal edema and vomitings.

Past history

Known case of Asthma since 10 years. She used inhaler.

Not a known case of diabetes mellitus, hypertension, epilepsy, coronary artery disease, cerebro vascular disease.

Diagnosed with koch's bacillus 1 and half month ago.

Personal history

Diet:mixed

Appetite:normal

Bowel and bladder:regular 

Addictions:none

General examination

The patient was unconscious on presention.

Pallor:absent, icterus:absent, clubbing :absent, cyanosis: , lymphadenopathy: absent.

GCS: 3/15 E1V1M3

PUIPILS: Unequal size

Before intubation:

BP: 90/60mm hg,   PR: 101bpm , CVS:S1 S2 heard   , RS: B/L wheeze   ,temp: 100.2f; GRBS:213 mg/dl

ABG: pO2: 77 mmhg

Patient on MV Settings: 

FiO2: 100, PEEP: 5cm hg, Vt :300ml, RR: 14bpm.

After intubated: 

BP:100/80,  PR:120, CVS: S1 and S2 heard,  RS: B/L coarse crepts 

ABG:  pO2:301mmhg

CNS EXAMINATION:

Patient on sedation

On 9/6  at 10am on admission

                                    Right                    left

Tone

Power        U/L          3/5                         1/5

                    L/L           1/5                         3/5

                     

Reflex                      biceps:absent    ,triceps: absent  ,                                   supinator: absent,  knee jerk:                                            absent;  ankle jerk: absent;                                             plantars:

On 10/6/21  at 8:00am

                                       Right                    left

Tone                              none                     none

Power        U/L          0/5                         0/5

                    L/L           0/5                         0/5

                     

Reflex                      biceps:absent    ,triceps: absent  ,                                   supinator: absent,  knee jerk:                                            absent;  ankle jerk: absent;                                             plantars:

 At 9:15 am 10/6
Patient went into sudden cardiac arrest without any recordable BP/PR  sPO2 30% on FiO2 100% of ACMV.
CPR was initiated according to the 2015 AHA GUIDLINES.     

Investigations

Hemogram, 

CRP

ESR

blood culture

ECG

chest X-ray

HIV, Rtpcr for COVID19, HbsAg

PROVISIONAL DIAGNOSIS:

Altered sensorium secondary to hanging 

Or tuberculous meningitis.

  Treatment :

1) IV 0.9 NS , RL and DNS continuous infusion, 100ml/hrs

2) Inj PAN 40mg IV OD

3) RT feed protein powder

4) ATT FDS (HRZE) 2 tab/ RT/ OD

5) Inj MIDAZOLAM 10gm in 40ml NS, 12.5 ml/hr,         continuous infusion 

6) GRBS charting 6th hourly

7) Temperature charting 4th hourly and tepid sponging

8) T. PCM 60mg/TID/RT

9) Strict I/O charting

10) monitor BP, PR, RR

11) Inj MANNITOL 100ml/IV/STAT

12) Inj AUGMENTIN 12mg/IV/OD

Under the guidance of Dr. Rashmitha and Dr. Vamsi General medicine PGs.