70 years old male with Altered sensorium

12th Jan 2022

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.

Name: K. Thanmai reddy

Roll.no:65

Batch :2017

A 70 year old male patient who is  daily wage labourer by  occupation was brought to the casualty on 6th jan with the chief complaints of altered sensorium since five days. Burning sensation in oral cavity, difficulty in swallowing, shortness of breath and productive cough since 25 days.

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 20days ago when he went on a sudden alcohol binge for a couple of days following which he developed cough assosciated with sputum (scanty, non foul smelling, non blood tinged) and

 Shortness of breath which was initially Class 2( slight limitation of physical activity) but gradually progressed to class 4(SOB at rest, unable to carry physical activity without discomfort).(NYHA)

 He also had burning sensation of the oral cavity since 25 days and pain on swallowing for which he was treated symptomatically by chlorhexidine mouth wash and mouthguard gel 

Following these complaints, the patient was taken to a nearby Government hospital, where he was treated symptomatically. 

Then the patient was shifted to another local hospital where a chest X Ray was done and he was told he has viral pneumonia of the right lung. 

Five days back(6th of jan) patient was brought to our hospital by his wife who said that she noticed a change in his responsiveness and slurring of speech that began 3 days ago. The patient presented to the casuality ward with some drowsiness, but he was arousable. 

On examination of his oral cavity, multiple erythematous lesions are seen over his hard palate 

PAST HISTORY :

No similar complaints in the past.

Not a known case  Diabetes mellitus

                                   Hypertension

                                    TB,

                                    Asthma, 

                                    Epilepsy,

                                     CAD.

H/o Surgery and blood transfusion:there history of transfusion of two units of FFP

Central line for dialysis on 7th jan

FAMILY HISTORY :

No history of similar illnesses among immediate family members. 

No significant family history.

The patient lost his first wife to an unknown illness 30 years ago. He has 2 daughters with his second wife. 

PERSONAL HISTORY:

Diet: Mixed 

Appetite: decreased recently

Sleep:Adequate 

Bowel and bladder: Decreased urine output

No known drug allergies

He consumes 150ml of Alcohol every other day, his last intake was 25 days back.

Tobacco usage since 30 years .

GENERAL EXAMINATION :

Patient is conscious, not coherant or cooperative, not oriented to time, place and he is drowsy,appears confused and irritated.

Moderately built and nourished. 

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

VITALS:

PR: 87 bpm

BP: 120/70 mmHg

RR: 24 cpm(tachypnic)

SpO2: 98% with 4L of O2

Temperature: febrile on arrival

GRBS: 229mg/dl

CNS:  GCS: E4V4M6

Cranial nerve examination intact

Speech slurred 

Sensory system- sensitive to pain, touch , vibration and temperature.

Motor system  :        Right.      Left    

                    Power-     UL 5/5     5/5

                                      LL 5/5     5/5 

                                 Neck ,trunk power normal 

          Tone-     UL      Normal      Normal

                         LL       Normal     Normal 

          Reflexes- 

Superficial reflexes - Intact 

                             Plantar   flexion  flexion

Deep tendon reflexes -

                           Biceps    ++             ++

                           Triceps  ++            ++

                         Supinator  ++          ++

                                Knee  ++           ++ 

                             Ankle     ++          ++ 

               

                               Gait- Normal

Cerebellar system - intact  

Respiratory system:  inspection:

 trachea central in position.

On auscultation:bilateral air entry present

  B/L Crepititions heard, NVB

On percussion:dullness on right upper lobe, 

CVS: S1, S2 heard, no murmurs

Abdominal examination:

Inspection: 

Shape of abdomen -scaphoid 

Position of Umbilicus- Central and inverted

All Quadrants of abdomen moving with respiration.

No visible scars and sinuses.

Hernial orifices free

No visible pulsations.

Palpation :

Soft

No tenderness

LIVER - Not Palpable

SPLEEN- Not Palpable 

Percussion :

NO SHIFTING DULLNESS

NO FLUID THRILL  

Auscultation :

Bowel sounds heard.

Investigations:

      Chest X-ray

Uric acid: 

Provisional diagnosis:

 altered sensorium secondary to uremic encephalopathy, viral pneumonia with acute kidney injury secondary to sepsis.

TREATMENT: 

-intravenous fluid ( normal saline,ringer lactate

- Ryle tube feeds 100 ml milk 2 nd hourly

                        50 ml water hourly

-Head end elevation 

- O2 inhalation to maintain spo2 >94%

- Inj.AUGMENTIN 1.2 gm IV BD

-Inj.HYDROCORTISONE 100mg IV/STAT

-tab.AZITHROMYCIN 500mg RT/OD

-tab.MONTEK-LC RT/OD

-tab.ACEBROPHYLLINE RT/OD

-NEB with BUDECORT -12th hourly.

                  IPRAVENT -4th hourly

                  MUCOMIST-2nd hourly 

-SYP AMBRONYL 15ml RT/TID

- temperature charting 

-GRBS- 6 th hourly

- Inj.LASIX 40mg IV/ BD( if BP > 110 mm Hg)

-Inj.PIPTAZ 45 mg IV/ STAT 

-MUCOPAIN gel

- BETADINE gargles T