A 42 Year old male with Altered Sensorium
August 16,2022
Chief Complain :
A 42 year old male was brought to casuality in a state of altered sensorium with history of fever since 10 days , vomiting since 10 days , generalised weakness and drowsiness since 10 days.
HOPI :
Patient was asymptomatic 1.5 years ago and then developed involuntary movements of upper limb and lower limb associated with uprollong of eyes and for which he was taken to alocal hospital and was diagnosed to be having alcoholic encephalopathy and dyseloctrolytemia for which he was treated conservatively and was discharged in a hemodynamically stable condition.
From then he was asymptomatic until 10 days ago , when he developed fever which is of low grade and relieved on medication and developed generalised weakness and vomiting 4-5 episodes in a day and the content are food particles and non- bilious and also associated with nausea. C/O generalised weakness and drowsiness since 10 days. With above complains patient visited multiple hospitals and received symptomatic treatment in the past 10 days and came to our hospital on 10/08/2022 for further management .
- No H/O headache , giddiness , seizures
- No H/O pain abdomen, loose stools
- No other complains
Past History
Not a known case of DM and HTN
Personal History
- Mixed diet
- decreased sleep and appetite
- chronic alcoholic
Family History : Not significant
Vitals at admission :
BP: 60/50
PR: 74bpm
RR: 16cpm
GRBS: 84mg/dL
Systemic examination :
RS: BAE + clear
CVS: S1S2 heard
P/A: soft, non-tender
CNS: Patient is drowsy, but arousable
E3V4M6
- No signs of meningeal irritation
- NFND
INVESTIGATIONS :
10/08/2022
11/08/2022
12/08/2022
13/08/2022
S. Creatinine : 0.5mg/dL
Blood Urea :12mg/dL
14/08/2022
15/08/2022
Morning
17/08/2022
Fever Chart
1.IV fluids
0.9%NS@150ml/hr
2.Inj.pantop 40mg iv/OD
3.Inj.zofer 4 mg iv/sos
4.Inj.neomol 100ml iv/sos
(If temp is more than 101 degree F)
5.Inj.thiamine 100mg iv/tid
6.Inj.cetriazone 2Gm iv/bd
7.Inj.Lorazepam2 cc IV (if seizure episode)
8.Inj.Levipil 500mg iv/bd
9.inj.meropenam iv/Bd (day 4)
10.Tab.Dolo650mg po/tid
.Monitor vitals-4rth hourly
I/O charting
My orientation around this case:
1.
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