A 40 YEAR OLD MALE WITH ALTERED MENTAL STATUS
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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.
40 year old male was brought to casualty with c/o altered mental status since 12 pm(21/2/24)
HOPI
Patient was apparently asymptomatic till 12 pm later developed altered mental status sudden in onset, incoherent to time,place, person.
H/o hallucinations since 5 days.
H/o sleep disturbances since 5 days
H/o fever since 15 days, intermittent,high grade a/w chills.
H/o slurred speech.
H/o weight loss
Noh/o vomitings,loose motions.
No H/o involuntary movements, up rolling of eyes, froth from mouth.
No H/o involuntary micturition, defecation
NoH/o cough,cold
PAST HISTORY:
H/o typhoid fever 2 months ago
Not a k/c/o DM, HTN,TB,ASTHMA, EPILEPSY, THYROID DISORDERS,CVA,CAD.
GENERAL PHYSICAL EXAMINATION:
PATIENT IS CONSCIOUS,NOT COHERENT AND NON COOPERATIVE.
Lymphadenopathy is seen in cervical region
No pallor,icterus, cyanosis, clubbing, edema .
VITALS AT ADMISSION:
TEMP-100.5F
BP-130/80 MMHG
PR-100BPM
RR-20 CPM
GRBS-134 MG/DL
SPO2- 98%AT ROOM AIR
SYSTEMIC EXAMINATION:
CVS- S1 S2 HEARD,NO MURMURS
RS-BAE+
PA- SOFT,NON TENDER
Central nervous system:
Higher mental functions - normal
Cranial nerves intact
Sensory system - pain , temperature, pressure , vibration
Motor system :
Tone - normal in upper and lower limb
Power. Right Left
Upper limb. 5/5. 5/5
Lower limb. 5/5 5/5
Reflexes:
Right. Left
Biceps +2 -
Triceps. +2 -
Supinator. + -
Knee +1 -
Ankle +1 +1
Plantar un elcitable
Cerebellar signs- cannot be elicited
No signs of meningeal irritation
Psychiatry Referral was done on 22/2/24 I/v/o Altered mental status,adviced tab chlordiazepoxide 25mg po od, nicotine gums po sos,Thiamine supplementation
DAY 1
Patient came to hospital on Wednesday (21/2/24) with C/O irrelevant speech and ataxia
MRI was done.
CSF ANALYSIS :
Patient tested HIV POSITIVE Since 2019 and on medication.
DAY 2:
PATIENT ORIENTED TO TIME, PLACE, PERSON WITH GCS E4 V5 M6
PSYCHIATRY REFERRAL DONE IV/O DELIRIUM TREMENS AND KORSAKOFF PSYCHOSIS AND ADVICED WITH TAB.LIBRIUM 25MG
DAY 3:
HRCT I/V/O CERVICAL LYMPHADENOPATHY:
IMPRESSION:
- CONSOLIDATION WITH THIN WALLED CAVITY IN APICAL AND POSTERIOR SEGMENT OF RIGHT LUNG UPPER LOBE. CENTRILOBULAR NODULES IN RIGHT LUNG UPPER LOBE
-SMALL NODULES SCATTERED IN REST OF THE LUNGS ON BOTH SIDES.
FNAC- LYMPH NODE LEFT CERVICAL NECK:
IMPRESSION:
FEATURES SUGGESTIVE OF NECROTISING LYMPHADENITIS
DAY 4:
SPUTUM FOR CULTURE AND SENSITIVITY:
ZN STAIN-ACID FAST BACILLI SEEN.
DIRECT SMEAR:
PLENTY OF PUS CELLS >25/CBF MODERATE EPITHELIAL CELLS 16- 18/LPF, MODERATE GRAM POSTIVE COCCI IN SINGLES, PAIRS, CHAINS FEW GRAM POSITIVE BACILLI, OCCASIONAL GRAM POSTIVE BUDDING YEAST CELLS SEEN.
CULTURE REPORT:METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS GROWN.
BAL FOR CULTURE AND SENSITIVITY:
DIRECT SMEAR-FEW EPITHELIAL CELLS, MODERATE PUS CELLS, FEW GRAM POSITIVE COCCI IN SINGLES PAIRS, FEW GRAM POSITIVE BUDDING YEAST CELLS SEEN
REPORT: ACID FAST BACILLI SEEN
METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS GROWN
DAY 5:
PATIENT WAS DROWSY AT DAY TIME AND IRRITABLE AT NIGHT TIME
DAY6:
PATIENT WAS DROWSY AND SWAYING TOWARDS LEFT SIDE AND WEAKNESS OF LOWER LIMB BUT ORIENTED TO TIME, PLACE, PERSON STARTED ON ATT (TRUNAAT POSITIVE AND AFB POSITIVE)
DAY 7:
AT 1 PM WEAKNESS OF UPPER LIMBS AND LOWER LIMBS
AT 6 PM PATIENT BECAME DROWSY AND GCS WAS LOW
MRI PLAIN: TUBERCULOUS MENINGITIS
ACUTE INFARCT IN RIGHT CG REGION R1 WITH DAPT
DAY 8:
MRI PLAIN AND CONTRAST:
IMPRESSION: K/C/O HIV POSITIVE
T 2 FLAIR INTRAPARENCHYMAL HYPERINTENSITIES IN THE MEDIAL TEMPORAL LOBE AND POSTEROLATERAL ASPECT OF BRAIN STEM ON RIGHT SIDE ON CONTRAST ADMINISTRATION, THERE IS SIGNIFICANT RIGHT SIDED LEPTOMENINGEAL ENHANCEMENT IN THE BASAL CISTERNS MEDIAL TEMPORAL LOBE SYLVIAN FISSURE AND POSTEROLATERAL ASPECT OF BRAINSTEM ON RIGHT SIDE
ON CONTRAST ADMINISTRATION THERE IS SIGNIFICANT RIGHT SIDED LEPTOMENINGEAL ENHANCEMENT IN THE BASAL CISTERNS,MEDIAL TEMPORAL LOBE, SYLVIAN FISSURE AND CEREBELLAR LEPTOMENINGES ENHANCEMENT ALONG THE SURFACE OF CISTERNAL SEGMENT OF TRIGEMINAL NERVE
D/D'S :
-TUBERCULOUS MENINGITIS
-HERPES SIMPLEX VIRUS MENINGOENCEPHALITIS
-NEURO MELIOTOSIS
-SMALL ACUTE INFARCT IN RIGHT LENTIFORM NUCLEUS VASCULITIC INFARCT DILATED PERI OPTIC CSF SPACES-TO RULE OUT RAISED INTRA CRANIAL TENSION
ON DAY 9:
GCS: E3 V4 M6
PUPILS:
LEFT- MILD DILATED SLUGGISHLY REACTIVE
RIGHT -CONSTRICTIVE,SLUGGISHLY REACTIVE
TONE: RIGHT. LEFT
UL- N DECREASED
LL - N. DECREASED
POWER : RIGHT. LEFT
UL. - 4/5. 0/5
LL - 4/5. 1/5
REFLEXS:
B. T. S K A. P
RIGHT- +2 +2 - +2 +2 Extensor
LEFT - +1. - - +1. +1 -
PA: Soft NT; Bowel sounds: Active
CVS :SIS2;No murmur
ON DAY 10 AND DAY 11:
PATIENT COMPLAINTS HICCUPS,STOOLS NOT PASSED SINCE 5 DAYS
ON EXAMINATION
PT IS DROWSY
GCS- E3 V4 M6
PUPILS:
LEFT- MILD DILATED SLUGGISHLY REACTIVE
RIGHT -CONSTRICTIVE.
TONE: RIGHT . LEFT
UL- N DECREASED
LL - N. DECREASED
POWER : RIGHT. LEFT
UL. - 4/5 0/5
LL - 4/5. 1/5
REFLEXS:
B. T. S K A . P
RIGHT- +2 +2 - +2 +2 Extensor
LEFT - +1. - - +1. +1 -
PA: Soft NT; Bowel sounds: Active
CVS :SIS2;No murmur
ON DAY 12:
PATIENT WAS DROWSY
GCS- E4 V1 M 4
PUPILS:
B/L: SLUGGISHLY REACTIVE
TONE: RIGHT LEFT
UL- N DECREASED
LL - N. DECREASED
POWER : RIGHT LEFT
UL. - 4/5 0/5
LL - 4/5. 1/5
REFLEXS:
B. T. S K A . P
RIGHT- +2 - - - - mute
LEFT - +2. - - - - mute
DAY 13 :
PATIENT IS DROWSY BUT AROUSABLE
GCS E3 V5 M6
PUPILS
RIGHT AND LEFT - NSRL
POWER : RIGHT LEFT
UL. - NORMAL 0/5
LL - NORMAL 1/5
REFLEXS:
B. T. S K A . P
RIGHT- +1 - - +2 +2. mute
LEFT - - - - - - mute
PATIENT WAS TREATED SYMPTOMATICALLY WITH ALL THE SUPPORTIVE TREATMENT .
INVESTIGATIONS:
HIV-POSITIVE
HBSAG -NEGATIVE
HCV- NEGATIVE
ON 21/2/24:
HEMOGRAM:
HB 9.6GM/DL
TLC 8700 CELLS/CUMM
PLATELET COUNT 2.4 LAKHS/CUMM
NORMOCYTIC NORMOCHROMIC ANEMIA WITH RELATIVE NEUTROPHILIA
ESR-125MM
BLOOD UREA -15 mg/dl
SERUM CREATININE 1.0 mg/dl
SERUM ELECTROLYTES (Na, K, CI) :
SODIUM 130 mEq/L
POTASSIUM 3.9 mEq/L
CHLORIDE 98 mEq/L
LIVER FUNCTION TEST (LFT) :
Total Bilirubin - 0.83 mg/dl
Direct Bilirubin- 0.20 mg/dl
SGOT(AST) 27 IU/L
SGPT(ALT) 43 IU/L
ALKALINE PHOSPHATASE 127 IU/L
TOTAL PROTEINS 7.7 gm/dl
ALBUMIN 3.1 gm/dl
A/G RATIO 0.67
RBS-121MG/DL
BLOOD GROUP-O POSITIVE
APTT -32 SEC
PT -16 SEC
INR-1.11
ON 23/2/24:
BLOOD UREA -18 MG/DL
HEMOGRAM:
HB 10.8GM/DL
TLC 8000 CELLS/CUMM
PLATELET COUNT2.59 LAKHS/CUMM
NORMOCYTIC NORMOCHROMIC ANEMIA
SERUM CREATININE -1.0MG/DL
SERUM ELECTROLYTES (Na, K, CI) :
SODIUM 130 mEq/L
POTASSIUM 3.9 mEq/L
CHLORIDE 98 mEq/L
ON 24/2/24
HEMOGRAM:
HB 10.9GM/DL
TLC 8700 CELLS/CUMM
PLATELET COUNT2.47LAKHS/CUMM
NORMOCYTIC NORMOCHROMIC ANEMIA
SERUM CRETAININE-1.0MG/DL
SERUM ELECTROLYTES (Na, K, CI):
SODIUM 131 mEq/L
POTASSIUM 3.7 mEq/L
CHLORIDE 99 mEq/L
BLOOD UREA -25MG/DL
SERUM CRETAININE-1.1MG/DL
ON 25/2/24
SERUM ELECTROLYTES (Na, K, CI)
SODIUM 135 mEq/L
POTASSIUM 4.1 mEq/L
CHLORIDE 99 mEq/L
On 26/2/24
HEMOGRAM:
HB 11.4GM/DL
TLC 8100 CELLS/CUMM
PLATELET COUNT2.24LAKHS/CUMM
NORMOCYTIC NORMOCHROMIC BLOOD PICTURE
ON 28/2/24
SERUM ELECTROLYTES (Na, K, CI)
SODIUM 135 mEq/L
POTASSIUM 3.8 mEq/L
CHLORIDE 98 mEq/L
SERUM ELECTROLYTES (Na, K, CI) 28-02-2024
SODIUM 112 mEq/L
POTASSIUM 4.1 mEq/L
CHLORIDE 80 mEq/L
ON 29/2/24
SERUM OSMOLALITY -228
SERUM ELECTROLYTES (Na, K, CI) :
SODIUM 119 mEq/L
POTASSIUM 4.2 mEq/L
CHLORIDE 81 mEq/L
SERUM ELECTROLYTES (Na, K,CL):
SODIUM 132 mEq/L
POTASSIUM 4.0 mEq/L
CHLORIDE 94 mE/L
SERUM CREATININE -0.9MG/DL
SERUM ELECTROLYTES (Na, K, CI) :
SODIUM 131 mEq/L
POTASSIUM 3.7 mEq/L
CHLORIDE 98 mEq/L
ON 1/3/24
SERUM ELECTROLYTES (Na, K,CL):
SODIUM 132 mEq/L
POTASSIUM 4.0 mEq/L
CHLORIDE 94 mE/L
SERUM CREATININE -0.9MG/DL
CUE:
ALB/SUGARS - TRACE/NIL
PUS CELLS/EPITHELIAL CELLS - 2-3/2-3
HEMOGRAM:
HB-11.2 GM/DL
TLC-9,800 CELLS/CUMM
PLATELET COUNT -2.74 LAKHS/CUMM
NORMOCYCTIC NORMOCHROMIC BLOOD PICTURE WITH NEUTROPHILIA
ON 3/3/24
CBP-
HB-10.8 GM/DL
TLC-10,000 CELLS/CUMM
PLATELET COUNT -3.06 LAKHS/CUMM
NORMOCYCTIC NORMOCHROMIC BLOOD PICTURE WITH NEUTROPHILIA
SERUM ELECTROLYTES (Na, K,CL):
SODIUM 134 mEq/L
POTASSIUM 4.4mEq/L
CHLORIDE 98 mE/L
ON 4/3/24:
SERUM ELECTROLYTES (Na, K,CL):
SODIUM 133 MEq/L
POTASSIUM 4.9mEq/L
CHLORIDE 89 mEq/L
ON 5/3/24
SERUM ELECTROLYTES (Na, K,CL):
SODIUM 138 MEq/L
POTASSIUM 4.5mEq/L
CHLORIDE 98 mEq/L
2D ECHO DONE ON 4/3/24:
CONCLUSION:
NO MR;MILD TR+; TRIVIAL AR+
NO RWMA. NO AS/MS SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION
NO PAH/PE
IVC- COLLAPSED.
2D ECHO DONE ON 22/2/24
CONCLUSION:
NO MR/AR/TR
NO RWMA NO AS/MS SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION
NO PAH/RF.
USG DONE ON 22/2/24.
IMPRESSION:
NO SONOLOGICAL ABNORMALITY
CSF CULTURE AND SENSITIVITY:
NO BACTERIAL GROWTH IN 48 HRS AEROBIC INCUBATION
SPUTUM FOR CULTURE AND SENSITIVITY:
ZN STAIN- ACID FAST BACILLI SEEN.
DIRECT SMEAR:
PLENTY OF PUS CELLS >25/CBF MODERATE EPITHELIAL CELLS 16- 18/LPF, MODERATE GRAM POSTIVE COCCI IN SINGLES, PAIRS, CHAINS FEW GRAM POSITIVE BACILLI, OCCASIONAL GRAM POSTIVE BUDDING YEAST CELLS SEEN.
CULTURE REPORT- METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS GROWN.
FNAC- LYMPH NODE LEFT CERVICAL NECK:
IMPRESSION- FEATURES SUGGESTIVE OF NECROTISING LYMPHADENITIS
CEREBROSPINAL FLUID MICROSCOPIC EXAMINATION - CYTO SMEAR STUDIES SHOWS FEW SCATTERED LYMPHOCYTES IN A CLEAR BACK GROUND.
HRCT CHEST ON 23/2/24
IMPRESSION-CONSOLIDATION WITH THIN WALLED CAVITY IN APICAL AND POSTERIOR SEGMENT OF RIGHT LUNG UPPER LOBE.
-CENTRILOBULAR NODULES IN RIGHT LUNG UPPER LOBE.
-SMALL NODULES SCATTERED IN REST OF THE LUNGS ON BOTH SIDES.
BAL FOR CULTURE AND SENSITIVITY:
DIRECT SMEAR-FEW EPITHELIAL CELLS, MODERATE PUS CELLS FEW GRAM POSITIVE COCCI IN SINGLES PAIRS, FEW GRAM POSITIVE BUDDING YEAST CELLS SEEN
REPORT: ACID FAST BACILLI SEEN
CHEST X RAY PA VIEW
ON 21/2/24
ON 26/2/24
ECG on 21/2/24
On 26/2/24
Treatment Given :
-IVF NS @ 50 ML/HR
-RT FEEDS 100ML WATER 2ND HOURLY
-INJ.LEVIPIL 500MG IV/BD
-TAB.BACTRIM DS PO/QID 1-1-1-1
-TAB.TLD RT/OD 0-0-1
-TAB.DTG 50 MG PO/OD 1-0-0
-INJ.THIAMINE 200MG IN 100ML NS IV/TID
-INJ.DEXA 6 MG IV/TID
-INJ.PAN 40 MG IV/OD
-INJ.NEOMOL 1 GM IV /SOS IF TEMP >101 F
-TAB.PCM 650MG PO/SOS
-TAB.BENADON 40 MG PO/OD 0-1-0
-INJ.ZOFER 4 MG IV/BD 1-0-1
-ATT 4FDC RT/OD BBF
1)TAB.ISONIAZID 5 MG/KG - 300MG
2)TAB.RIFAMPACIN 10 MG/KG - 600MG
3)TAB.PYRIZINAMIDE 25MG/KG-1600MG
4)TAB.ETHAMBUTAL 15 MG/KG-1100MG
-TAB.ECOSPIRIN 150MG RT/HS
-TAB.CLOPIDOGREL 75 MG RT/HS
-INJ.3%NACL @10 ML/HR
-TAB.TOLVAPTAN 30MG PO/OD
-TAB.ITRACONAZOLE 200MG PO/BD
-TAB. ITRACONAZOLE 200 MG RT/BD
-TAB.ATORVAS 40 MG RT/HS.
-SYP.DVLCOLAX 15 ML RT HS 0-0-1
- AIR BED
-PHYSIOTHERAPY OF LEFT LOWER AND UPPER LIMBS
2ND HOURLY POSITION CHANGE.
DIAGNOSIS :
LEFT HEMIPARESIS SECONDARY TO ACUTE INFRACT IN RIGHT THALAMUS AND RIGHT BASAL GANGLIA SECONDARY TO CNS VASCULITIS.
? TUBERCULOSIS MENINGITIS
? HERPES SIMPLEX VIRUS MENINGO CEPHALITIS
? NEUROMELIOIDOSIS.
ACTIVE PULMONARY TB, PNEUMOCYSTIS JIROVECII PNEUMONIA
HYPONATREMIA SECONDARY TO ? SIADH
KORSAKOFF PSYCHOSIS
RVD POSTIVE SINCE 2019
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