21 OLD MALE WITH ALTERED SENSORIUM

 MEDICINE E LOG BOOK

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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 plan.

Chief complaints:

Pt came to casualty in state of altered sensorium with slurring of speech since yesterday

History of presenting illness :

Pt does hotel management and stays alone.

He was apparently asymptomatic 5 days back. He had fever 5 days back which was high grade, continuous, associated with chills and rigors. No history of cold and cough . He went to local hospital got treated but the fever did not subside.

Later after a day he consumed beer, had biryani.

He had 1 episode of vomiting and loose stools since 3 days. (2 days back), while he was in room suddenly he had involuntary movements of all 4 limbs associated with frothing, uprolling of eyes, post ictal confusion, he bit his lower lip  no tongue bite . He had 1 episode of vomiting at the time of involuntary movement, and loose stools. 

Loose stools, foul smelling. 

Since yesterday afternoon, pt was in altered sensorium , with slurred speech, and deviation of mouth.

He was presented to hospital on 19/09/22 and was treated he was sedated at 1am  was sent home at 4:30am . He woke up at 2pm . He had altered sensorium and involuntary movements. 

No c/o weakness of upper limb and lower limb.

No h/o cough, cold, palpitations, syncopal attacks, chest pain

PAST HISTORY 

N/k/c/o - DM, HTN, EPILEPSY,TB , ASTHMA 

FAMILY HISTORY

No significant history 

PERSONAL HISTORY

appetite- normal 

Diet- mixed

Bowel and bladder - normal 

Sleep- regular

Habits - alcohol consumption occasionally,

Smoking 

General examination:

On examination: 

Pt is in altered sensorium

No pallor, Icterus, clubbing, cyanosis lymphadenopathy, edema

VITALS

BP-110/70mmhg

PR - 85bpm 

RR -16 cpm

Temp. 100°F

CVS S1, S2 +

RS - BAE +, NVBS 

Per abdomen - soft and non tender

CNS EXAMINATION:

NERVOUS SYSTEM EXAMINATION 

a. Conscious

 b. Not Oriented to time, place and person

 c. Speech and language –no aphasia, dysarthria, dysphonia 

d. Memory – immediate-retention and recall, recent and remote - not intact 

MOTOR examination 

Meningeal signs

Kernigs sign +

Brudzinski sign -

Power:

                       Rt.                   Lt

UL                 +4/5.              -4/5

LL.                +4/5.              -4/5

Tone 

UL.                N                        N

LL.                 N.                       N

Hand grip:  100%.                100%

Provisional Diagnosis : Altered sensorium under evaluation 2° to dengue encephalitis with pre renal AKI 2° to acute gastroenteritis. 

Investigations 

 

 

Treatment