64 year old male presented with altered sensorium and unable to speak

 January 05 2023 

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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment.

CHIEF COMPLAINTS

Patient admited on 28/12/2022 

64 year old male presented with complaints of cough since 15days

Bowel and bladder incontinence and loss of appetite since 12 days 

Fever since 12 days 

Hicupps since 9 days

Unable to speak since 9 days but concious and inchorent.

HISTORY PRESENTING ILLNESS

Patient was apparently asymptomatic 15 days back then he developed cough which is insidious in onset and gradually progressive which is productive in nature .

He developed bowel and bladder incontinence along with loss of appetite since 12 days. 

He developed loose stools 8 days back about 5 episodes per day last for 1 day which subsided on taking medication. 

He developed hiccups 8 days back 

Since 25/12/22 he is unable to talk .

No history of shortness of breath and palpitations.

No history of loss of consciousness, giddiness 

Patient was diagnosed with type 2 diabetes mellitus but no medications was taken for 3 years then from past 4years he is talking metformin and glimiperide once daily.

4 years back he developed shortening of breath then he went to local hospital there he was diagnosed with asthama 

2 years back he developed jaundice and hicupps then he was treated.

15 days back on 22 December 2022 he had cough and hicupps followed by bowel and bladder incompitance he had loose stools 5 episodes on that day 

On 25 December 2022 he was unable to speak and bowel and bladder incontinence developed and he was unable to speak but he concious and uncoporative and incoherent.

On 28 December 2022 he was bought to the hospital.

PAST HISTORY

History of panic attack one month back due to family issues.

History of Diabetes since 7 years 

No history of hypertension, epilepsy, tuberculosis,CAD, CVD.

PERSONAL HISTORY

Patient was daily labourer, he stoped working from past 3years , from last three years he is unable to walk properly he uses stick for help.

Diet mixed 

Appetite - lost 

Sleep - adequate 

Bowel and bladder movements - incontinence

Addictions - occasional alcoholic, tobacco chewing - daily since 30 years.

Allergies - no 

FAMILY HISTORY

History of tuberculosis in the family.

GENERAL EXAMINATION

Patient is conscious uncoporative and incoherent

He is moderately built and nourished 

Pallor : present 

Icterus : absent 

Cyanosis: absent 

Lymphadenopathy : absent 

Edema : absent 

Pectus excavatum 

Flexion deformity in both the knees.

VITALS

Temperature - afebrile 

BP : 100 / 50 mmHg 

PR : 120 bpm 

RR : 16 cpm 

SPO2 : 98 % at RA

GRBS : 193 mg/dl 

SYSTEMIC EXAMINATION

Central nervous system examination

GCS 

E4 

V2

M1 

Sensory system

Pain , touch , temp , vibration, joint position no response

Motor system -               

                            Right            left 

Tone          UL  hypo.           Hypo. 

                    LL   hypo.         Hypo.  

Power.   UL and LL no movement even with pain 

Reflexes not elicited

Brain stem reflexes 

Bilateral corneal +, conjunctival + papillary+

Cranial  nerves intact 

Finger nose in coordination no 

Heel ankle in coordination no 

CVS 

S1,S2 heard , no murmurs and thrills 

Respiratory system

Decreased air entry on left side, crackles are heard , postion of trachea central.

Abdomen - soft , non tender,no organomegaly

INVESTIGATION

On 28 /12 / 2022

CSF cytology

On 4/ 01/2023

On 05 / 1/ 2023

Provisional diagnosis - 

Altered sensorium secondary to meningoencephalitis (? TB ) 

Left sided pneumonia ( ?TB ) 

Pre renal AKI

Bilateral fixed flexion deformity since 2 years.

Treatment 

IVF 0.9% NS IV @100 ml /hr 

Nebulization with duolin - 8th hrly budercort - 12hr

Inj. Thiamine 200mg IV/ BD in 100 ml NS 

Inj.Dexa 6mg IV / TID 

ATT therapy pO/ OD : FDC : 3 tab / day 

GRBS monitoring 6th hrly

VITALS monitoring 6th hrly

Temp monitoring - 4th hrly 

Inj H. Actrapid insulin SC TID acc to GRBS 

RT  feeds 100 milk 3+4 scoops protein powder 4th hrly , 50 ml H2O 2nd hrly 

Physiotherapy was done