70Year Old Male with Altered Sensorium

70Year Old Male with Altered Sensorium

January 11, 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.

A 70 year old male who is a daily wage labourer by occupation was brought to the casualty ward with the chief complaints of altered sensorium since 5 days and fever, shortness of breath and a productive cough since 25 days

Timeline:
25 days ago:The patient was apparently asymptomatic 25 days 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 sanguinous) and shortness of breath that could initially be classified under Class 2 NYHA(SOB with ordinary activity, slight limitation of physical activity) but gradually progressed to class 4(SOB at rest, severe limitation of physical activity). He also had burning sensation of the oral cavity that he recalls to have begun around the same time.

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

22 days ago: 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. 

5 days ago: The 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 5 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.
No H/o DM ,HTN, TB, Asthma, epilepsy,CAD
History of surgeries or blood transfusion:
History of transfusion of two units of FFP
Central line for dialysis on 7th January.


FAMILY HISTORY:
No history of similar illnesses among immediate family members. 
The patient lost his first wife to an unknown illness 30 years ago. He has 2 daughters with his second wife. 
No history of CKD, DM,HTN,CVA, TB, Asthma or CAD among his immediate family members. 


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 person. He appears confused and irritated.
Moderately built and nourished. 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema. 

VITALS:
Temperature: febrile on arrival
PR: 87 bpm
BP: 120/70 mmHg
RR: 24 cpm
SpO2: 98% with 4L of O2
GRBS: 229mg/dl

SYSTEMIC EXAMINATION:
CNS: 
Higher motor functions-
Speech: slurred
Cranial nerve functions - Intact. 
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 Normal 
                 Trunk muscles Normal  

          Tone- UL Normal Normal
                         LL Normal Normal 

          Reflexes- 
Superficial reflexes - Intact 
                             Plantar flexion flexion
Deep tendon reflexes -
                           Biceps ++ ++
                           Triceps ++ ++
                         Supinator ++ ++
                                Knee ++ ++ 
                             Ankle +++
                            Gait- +++
                 Cerebellar system - intact


Respiratory system: 
Inspection:
trachea central in position.
On percussion:dullness on right upper lobe
On auscultation:bilateral air entry present,NVBS
                          B/L Creptititions heard

CVS: 

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation:S1, S2 Heard, no added murmurs.

P/A: Soft, non tender 

Inspection: 
Shape of abdomen -scaphoid 
Position of Umbilicus- Central and inverted
All Quadrants of abdomen moving with respiration.
No visible scars and sinuses.
No visible pulsations.

Palpation :
SOFT
NO TENDERNESS 
LIVER - Not Palpable
SPLEEN- Not Palpable
 
Percussion :
NO SHIFTING DULLNESS
NO FLUID THRILL 

Auscultation:
BOWEL SOUNDS WERE HEARD. 


Investigations: 
Blood grouping and Rh typing :


Chest X ray: 






HIV Rapid :



Covid RT-PCR: NEGATIVE (tested on arrival) 
Sputum for AFB: NEGATIVE

USG Abdomen :


 PROVISIONAL DIAGNOSIS:

Altered sensorium as a consequence of exacerbated uremic encephelopathy along with acute kidney injury secondary to sepsis, viral pneumonia of the right upper lobe in a 70 year old





TREATMENT: 

intravenous fluid ( normal saline,ringer lactate)

- Ryle tube feeds 100 ml milk 2 nd hourly


                       50 ml water hourly

1. MUCOPAIN Gel BD* 1 week

2. BETADINE mouth gargles TID* 1 week

3. Tab MVT OD* 15 days

4. Inj PIPTAZ 2.25gm TID

5. THIAMINE in 100ml normal saline TID

6. Tab AZITHROMYCIN 500mg*PO/OD

7. Inj LASIX 40mg IV BD

8. Tab Montek-LC

9. Tab ACEBROPHYLLINE

10. Tab Pulmoclear PO OD

11. Syp: Ambroxyl 15ml PO TID

12. Nebulizer with BUDECORT- 8th hourly

Duolin- 12th hourly

13. Inj HYDROCORTISONE 100mg IV stat

14. Inj VIT K 1 ampoule in 100ml NS for slow IV 

Other measures: Head elevation

Vitals checked every 4hrs

 O2 inhalation to maintain SpO2 greater than 94%

Monitor urinary output

GRBS every 6th hourly

Chest physiotherapy 

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