A 75 YEARS OLD MALE WITH ALTERED SENSORIUM
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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CASE DISCUSSION:
A 75 year old male came with complaints of
- fever since 10 days
- altered sensorium since 5 days
HOPI:
Patient was apparently asymptomatic 10 days back and then developed fever which was high grade not associated with chills and rigor. Then he developed altered sensorium since 5 days he was not able to recognise his family members.
PAST HISTORY:
Not a K/C/O DM, HTN, TB,EPILEPSY, ASTHMA
Has hypo-pigmented patches on b/l lower limbs and b/l nipples since 6 years using herbal medication regularly, itching is present.
PERSONAL HISTORY:
He is Married
He consumes
- Mixed diet
- sleep is adequate
- Appetite normal
- bowel and bladder movements are regular
- He Consumes Alcohol twice a week (90ml) since 50 years presently abstinent since 15 days
- He smokes beedi 1-2 packs/day since 55 years
FAMILY HISTORY: no similar complaints in the family.
DAILY ROUTINE: Wakes up early in the morning around 5:00am and then goes to the farm, comes back home at 10:00am has breakfast (Tea and bread or some tiffin), from 10:00am to 6:00pm he stays home takes rest and does house chores. Takes his meals on time (3 meals/day).
Sleeps at 10:00pm and the routine continues.
CLINICAL IMAGES:
GENERAL EXAMINATION:
Patient is conscious ,non-cooperative, not oriented to time, place and person.
Thinly built and nourished.
VITALS:
BP: 120/70mmhg
PR: 90bpm
RR: 20cpm
Temp: 100f
SYSTEMIC EXAMINATION:
RS:
Inspection : barrel shape
Decreased breath sounds on right side
Diffuse expiratory wheeze
CVS: s1,s2 no added sounds
P/A: not tender
Pt is altered
GCS - E3V1M6
Speech - making incomprensible sounds
Pupils:NSRL
Motor
Power : Not moving his left upper limb and lower limb as actively as right side
Tone : Normal
Reflexes : B T S A K P
R: - - - - - Flexion
L : - - - - - Flexion
Neck rigidity : Present
Kerning's : Positive
Brudzski : Negative
PROVISIONAL DIAGNOSIS: ALTERED SENSORIUM UNDER EVALUATION
INVESTIGATIONS:
On Day1
ABG: Day 1 at 10:43pm
ABG: Day 1 at 11:51pm
LP PROCEDURE 1:
2D ECHO:
TREATMENT:
1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD
2.INJ.IVF DNS 50ml/hr
3.INJ.PANTOP 40mg IV/OD
4.INJ.ZOFER 4mg IV/SOS
5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD
6.MONITOR VITALS EVERY 6th hrly
7.GRBS MONITORING EVERY 4th
Day 2
S: fever since 10 days and altered sensorium since 5 days
Presently altered sensorium
O: pt is conscious,uncooperative,not oriented to time,place and person.
BP: 120/70mmhg
PR: 90bpm
RR: 20cpm
Temp: 98.6f
SYSTEMIC EXAMINATION:
RS:
Inspection : barrel shape
Decreased breath sounds on right side
Diffuse expiratory wheeze
CVS: s1,s2 no added sounds
P/A: not tender
CNS:
Pt is altered
GCS - E3V1M6
Speech - making incomprensible sounds
Motor
Power : Not moving his left upper limb and lower limb as actively as right side
Tone : Normal
Reflexes : B T S A K P
R: - - - - - Flexion
L : - - - - - Flexion
Neck rigidity : Present
Kerning's : Positive
Brudzski : Negative
A: ?Altered sensorium under evaluation
?Alcohol withdrawal syndrome
P:
1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD
2.INJ.IVF DNS 50ml/hr
3.INJ.PANTOP 40mg IV/OD
4.INJ.ZOFER 4mg IV/SOS
5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD
6.MONITOR VITALS EVERY 6th hrly
7.GRBS MONITORING EVERY 4th hrly
INVESTIGATIONS:
ABG: Day 2 at 6:17 am
ABG: Day 2 at 4:46pm
Plan: Patient intubated on ACMV VC MODE as he was hypoxic Post Intubation Ventilator Settings :
RR - 16
Fio2 - 40
PEEP - 5
TV - 400
Post Intubation Vitals :
Pupils - B/L Fixed Pin point Pupils
BP - 100/70mmHg
PR - 116/Min
RR - 22/Min
Spo2 - 100%
Midaz Infusio - 5ml/hr
Atracurium Infusion - 10ml/hr
ABG:Day 2 at 9:50pm
Day 3
S:pt is on mechanical ventilator and sedation
O: pt on SIMV VC mode
RR TOTAL: 29
RR:20
Fio2:30%
PEEP: 5 cm of H2O
TV:400
VITALS:
BP: 110/70mmhg
PR: 82bpm
RR: 16cpm
Temp: 98.5f
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender
A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.
P:
TREATMENT:
1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD
2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly
3.INJ.PANTOP 40mg IV/OD
4.INJ.ZOFER 4mg IV/SOS
5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD
6.Inj.NEOMOL IV if TEMP>102f sos
7.GRBS MONITORING EVERY 4th hrly
8.Inj.MIDAZ 5ml/hr
9.Tab. Azithromycin 500mg PO/OD
CT SCAN BRAIN:
Day 3 At 9:30 am
Pt was able to breath on its own so the changes were done to SIMV -VC Mode
RR Total - 29
RR - 16
Fio2 - 30
PEEP - 5
VT - 400
Vitals -
BP - 100/80
RR - 38/min
HR - 108/min
Spo2 - 97
ABG: Day 3 at 12:20pm
ABG: Day 3 at 9:20pm
On Day 4
S:pt is on mechanical ventilator and sedation
O: pt on SIMV VC mode
RR TOTAL: 29
RR:20
Fio2:30%
PEEP: 5 cm of H2O
TV:400
VITALS:
BP: 110/70mmhg
PR: 97bpm
RR: 16cpm
Temp: 97.6f
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender
A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.
P:
TREATMENT:
1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD
2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly
3.INJ.PANTOP 40mg IV/OD
4.INJ.ZOFER 4mg IV/SOS
5.INJ.OPTINEURON 1AMP IN 100ml NS IV/OD
6.Inj.NEOMOL IV if TEMP>102f sos
7.GRBS MONITORING EVERY 4th hrly
ABG: Day 4 At 9:00am
CULTURE REPORT:
ABG: Day 4 at 1:36pm
ABG: Day 4 at 10:36pm
ABG: Day 5 at 6:30am
Day 5
S:pt is on mechanical ventilator and sedation
O: pt on SIMV VC mode
RR TOTAL: 34
RR:16
Fio2:21%
PEEP: 5 cm of H2O
TV:400
VITALS:
BP: 130/70mmhg
PR: 122bpm
RR: 20cpm
Temp: 100.8f
SpO2: 97%
GRBS: 327 mg/dl
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender
CNS:
Doll’s eye reflex +
Pt is unresponsive
GCS - E1VTM1
Pupils:B/L equal constricted and reacting to light.
R L
Corneal + +
Conjunctival. +. +
Tone : Hypotonia
Reflexes : B T S A K P
R: - - - - - Flexion
L : - + - - - Flexion
A: Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.
P:
TREATMENT:
1.INJ.CEFTRIAXONE 2gm IV/STAT then 1gm IV/BD
2.RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hourly
3.INJ.PANTOP 40mg IV/OD
4.INJ.ZOFER 4mg IV/SOS
5.INJ.Dexamethasone 4mg BD
6.Inj.NEOMOL IV if TEMP>102f sos
7.GRBS MONITORING EVERY 4th hrly
8.INJ.Clexane 40mg S/C OD
9.Tab. Azithromycin 500mg PO/OD
10.NEB BUDECORT 12th hrly DUOLINE 8th hourly
11.Monitor vitals
Day 5 at 3:50pm
Day 6
S:pt removed from ventilation and was put on T. Piece since today morning 7.30 am
O:
Pt conscious
GCS:E4VTM4
spontaneous eye opening +
Spontaneous breathing +
VITALS:
BP: 120/70mmhg
PR: 137bpm
RR: 30cpm
Temp: 101.3f
SpO2: 98%
GRBS: 197 mg/dl at 8:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD.
P:
Plan to extubate
ABG: Day 6 at 6:20am
ABG: Day 6 at 9:30am
Urine culture report:
Day 7
S:pt extubated yesterday at 4:00pm
Bed sores at sacral area
O:
Pt conscious
GCS: E4V5M3
spontaneous eye opening +
Spontaneous breathing +
VITALS:
BP: 120/70mmhg
PR: 98bpm
RR: 33cpm
Temp: 98.7f
SpO2: 98%
GRBS: 335 mg/dl at 8:00am
CSF reports awaiting
URINE CULTURE:
isolated E.coli sensitive to :
Nitrofurantoin
Gentamicin
Cotrimoxazole
Fosfomycin
Amikacin
Tazobactum
Clavulenic acid
Meropenam
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD, BED SORES + (sacral area Grade II)
P:
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.Neomol 1gm/IV/TEMP>102f
Neb with budecort 12th hrly, duoline 8th hourly
Frequent change of position every 2nd hrly
Procedures: LP Procedure done at 8:00am today
LP PROCEDURE 2: https://youtu.be/C6OxUWOwoc0
ABG:Day 7 at 6:00pm
Day 8
S:
Bed sores at sacral area
O:
Pt conscious
GCS: E4V5M3
spontaneous eye opening +
Spontaneous breathing +
VITALS:
BP: 120/70mmhg
PR: 92bpm
RR: 22cpm
Temp: 98.5f
GRBS: 345mg/dl at 8:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD, BED SORES + (sacral area Grade II)
P:
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.Neomol 1gm/IV/TEMP>102f
Neb with budecort 12th hrly, duoline 8th hourly
Frequent change of position every 2nd hrly
ABG: day 8 at 6:00am
Day 9
S:
Bed sores at sacral area
O:
Pt conscious
GCS: E4V5M3
spontaneous eye opening +
Spontaneous breathing +
VITALS:
BP: 120/70mmhg
PR: 92bpm
RR: 22cpm
Temp: 98.5f
GRBS: 345mg/dl at 8:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD, BED SORES + (sacral area Grade II)
P:
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.Neomol 1gm/IV/TEMP>102f
Neb with budecort 12th hrly, duoline 8th hourly
Frequent change of position every 2nd hrly
ABG: day 9 at 8:00am
Day 10
S:
Bed sores at sacral area
Dressing is done
O:
Pt conscious
GCS:E4V4M3
VITALS:
BP: 110/70mmhg
PR: 96bpm
RR: 30cpm
Temp: 98.5f
GRBS: 195mg/dl at 8:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD, BED SORES + (sacral area Grade II)
P:
Mobilise him with support
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.Neomol 1gm/IV/TEMP>102f
Neb with budecort 12th hrly, duoline 8th hourly
Frequent change of position every 2nd hrly
Day 11
S:
Bed sores at sacral area grade 2-3
O:
Pt conscious
GCS:E4M6V3
VITALS:
BP: 110/70mmhg
PR: 94bpm
RR: 26cpm
Temp: 98F
GRBS: 235mg/dl at 8:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD, BED SORES + (sacral area Grade II)
P:
Mobilise him with support
RT FEEDS 100ml milk 4th hrly, 50ml water 2nd hrly
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.Neomol 1gm/IV/TEMP>102f
Neb with budecort 12th hrly, duoline 8th hourly
Frequent change of position every 2nd hrly
Day 12
S:
Bed sores at sacral area grade 2-3
Irrelevant talk
O:
Pt conscious, not oriented to time,person
GCS:E4M6V3
VITALS:
BP: 110/70mmhg
PR: 82bpm
RR: 26cpm
Temp: 98.6f
GRBS: 124 mg/dl at 8:00am
SYSTEMIC EXAMINATION:
CVS: s1,s2 no added sounds
P/A: not tender,Soft
RS:BAE+
A: fever with Altered sensorium secondary to meningitis with type 1 respiratory failure with acute exacerbation of COPD, BED SORES + (sacral area Grade II)
P:
Mobilise him with support
Inj.PAN 40mg/IV/OD
Inj.Zofer 4mg/IV/SOS
Inj.Neomol 1gm/IV/TEMP>102f
Neb with budecort 12th hrly, duoline 8th hourly
Frequent change of position every 2nd hrly with ambulation.
2D ECHO REVIEW:https://youtu.be/R44GG352Gg4
ABG TRENDS:
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