A 64 YR OLD WHO IS UNABLE TO TALK SINCE 1 DAY
28/12/2022
G MEGHANA , INTERN
Roll.no :51
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hemogram
RBS
LFT
chest XRay AP view
I’ve 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
CASE :
CHIEF COMPLAINTS :
Patient came to casuality with chief complaints of
- unable to talk since 1 day
- hiccups since 7 days
- bowel and bladder incontinence, loss of appetite since 3 days
- loose stools 5 days back relieved on medication
- fever 4 days back
History of present illness :-
Patient was apparently asymptomatic 7 days back , he then developed hiccups , loss of speech
- 5 days back he developed diarrhoea 5 episodes/ day , for one day which was relieved on medication
-loss of appetite since 3 days , since one day he is unable to talk
- No H/O SOB , cough , palpitations
- No H/O loss of consciousness , giddiness , involuntary passage of urine and stools .
Past history :-
- h/o panic attack one month back secondary to family issues
- K/C/O DM2 since 2 yrs , on medication ,
-tab Metformin OD , tab Glimiperide OD
- Not a K/C/O HTN, TB, Asthma, epilepsy, CAD, CVD
Personal History :-
Appetite - lost
Diet - Mixed
Sleep - adequate
Bowel and bladder movements - incontinence
Addictions: Occasional alcoholic ( during functions ) , tobacco chewing occasionally
Allergies : No allergies
Family history :- not significant
GENERAL EXAMINATION:
Patient is conscious ,incoherent , uncooperative
Moderately Built and Moderately Nourished .
Pallor : present
Icterus : absent
Cyanosis: absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
His vitals :-
Temp: Afebrile
BP : 100 / 50 mmHg
PR : 120 bpm
RR : 16 cpm
SPO2 : 98 % at RA
GRBS : 193 mg/dl
SYSTEMIC EXAMINATION:
CNS examination :-
State of consciousness : conscious
Speech : incoherent
Kernigs sign :- positive
Sensory system :-
Pain - Normal
Touch- fine touch - normal
crude touch - normal
Temp - normal
Vibration - normal
Joint position - normal
Cranial nerves : intact
CNS :-
Right. Left
Tone :- UL hyper hyper
LL. Hyper hyper
Power :- UL and LL moving all four limbs in response to pain
Reflexes :-
Biceps + +
Tricep s + +
Supinator + +
Knee + +
Ankle. ++
Flexor. Plantar. Plantar
Finger nose in coordination - no
Heel knee in coordination - no
CVS : S1 S2 + ,no murmurs ,no thrills
Respiratory System : decreased air entry on left side . Diffuse crepts on left side. Position of trachea - central.
Per abdominal examination:-
Soft , non tender , no signs of hi organomegaly
Investigations:-
ECG
Chest x ray pa view ;-
USG abdomen:-
MRI brain :-
serum electrolytes :-
provisional diagnosis:-
CVA , hyponatremia
Management:-
1) IVF 0.9 %NS IV @ 50 ml / hr
2) Inj , 1 amp Optineuron in 500 ml NS IV /OD
3) tab Ecosprin AV 75/10 RT / OD / HS
4) GRBS monitoring 6 th hrly
5) Inj Thiamine 200 mg IV/BD in 100 ml NS
29/12/2022 :-
AMC
Bed 4
Day 2
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S :
No fresh complaints
O :
Patient is conscious , non coherent, non cooperative
BP :110/60 mm hg
PR :- 110 bpm
RR : 16 cpm
Temp : 98 F
Spo2 : 98 % at RA
CVS : S1 , S2 heard, no murmurs
RS : BAE + , decreased air entry on left side , no wheeze , no crepts
CNS :-
Reflexes :- right. Left
Biceps - -
Triceps - -
Supinator - -
Knee -. -
Ankle - -
GCS : E4V1M4
Right. Left
Tone :- UL hyper hyper
LL hyper hyper
Power :- UL : moving all four limbs in LL : response to pain
P/A : soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis
- hyponatremia
- AIS ( Tiny acute infarct in right temporal lobe )
P :
) IVF 0.9 %NS IV @ 50 ml / hr
2) Inj , 1 amp Optineuron in 500 ml NS IV /OD
3) tab Ecosprin AV 75/10 RT / OD / HS
4) GRBS monitoring 6 th hrly
5) Inj .Thiamine 200 mg IV/BD in 100 ml NS
6) T.Baclofen 10 mg RT/TID
Lumbar puncture video performed on 29/12/2022 at 12 pm
On 30/12/2022
ICU
Bed 6
Day 2
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S:
No fever spikes
Stools passed
O :
Patient is drowsy but arousable
BP :120/80 mm hg
PR :- 102 bpm
RR : 17 cpm
Temp : 98 F
Spo2 : 98 % at RA
GRBS :- 275 mg/dl
I/O : 1500/900 ml
CNS :- GCS : E3V4M6
CVS : S1 , S2 heard, no murmurs
RS : BAE + , decreased air entry on left side , crepts +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left sided pneumonia ( ?TB )
P :
Patient was started on ATT
1) IVF 0.9 %NS IV @ 75 ml / hr
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj , 1 amp Optineuron in 500 ml NS IV /OD
4) Inj .Thiamine 200 mg IV/BD in 100 ml NS
5) Inj .Monocef 2 gm IV/BD
7) Inj . Dexa 6 mg IV / TID
9) ATT therapy PO/OD
10) GRBS monitoring 6 th hrly
11) vitals monitoring 6 th hrly
12) Temp monitoring 4 th hrly
13) Inj H. Actrapid insulin SC TID acc to GRBS
31/12/2022:
Bed 6
Day 3
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S :
Pt in altered sensorium
O :
Patient is drowsy but arousable
BP :120/80 mm hg
PR :- 102 bpm
RR : 17 cpm
Temp : 98 F
Spo2 : 98 % at RA
GRBS :- 246 mg/dl
I/O : 2100/1100 ml
CNS :- GCS : E2V1M4
Right. Left
Tone :- UL hypo hypo
LL hypo hypo
Power :- UL : moving all four limbs in LL : response to pain
CVS : S1 , S2 heard, no murmurs
RS : BAE + , decreased air entry on left side , crepts +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left sided pneumonia ( ?TB )
P :
1) IVF 0.9 %NS IV @ 75 ml / hr
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS
4) Inj . Dexa 6 mg IV / TID
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
1/1/2023 :-
1) IVF 0.9 %NS IV @ 75 ml / hr
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS
4) Inj . Dexa 6 mg IV / TID
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
SOAP NOTES
2/1 /2023
ICU
Bed 6
Day 5
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S:
Pt in altered sensorium
O :
Patient is stuporous
BP :110/70 mm hg
PR :- 107 bpm
RR : 17 cpm
Temp : 98 F
Spo2 : 98 % at RA
GRBS :- 146 mg/dl
I/O : 2100/1100 ml
CNS :- GCS : E4V1M1
Right. Left
Tone :- UL hypo hypo
LL hypo hypo
Power :- UL : not moving even with pain LL :
Reflexes:-not elicited
Brain stem reflexes :-
B/L corneal + ,conjuctival + , pupillary + ,
Doll's eye : absent on left
Gag :+
Plantar : left - , right - increased
CVS : S1 , S2 heard, no murmurs
RS : BAE + , crepts +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left sided pneumonia ( ?TB )
P:-
) IVF 0.9 %NS IV @ 75 ml / hr
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS
4) Inj . Dexa 6 mg IV / TID
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
Investigations :-
CBNAAT OF CSF : NEGATIVE
3/1/2023:
ICU
Bed 6
Day 6
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S : no fresh complaints
O:Patient is stuporous
BP :110/70 mm hg
PR :- 102 bpm
RR : 17 cpm
Temp : 98 F
Spo2 : 98 % at RA
GRBS :- 146 mg/dl
I/O : 2100/1100 ml
CNS :- GCS : E4V1M1
Right. Left
Tone :- UL hypo hypo
LL hypo hypo
Power :- UL and LL : not moving even with pain
Reflexes:-not elicited
Brain stem reflexes :-
B/L corneal + ,conjuctival + , pupillary + ,
Doll's eye : absent on left
Gag :+
Plantar : left - , right - increased
CVS : S1 , S2 heard, no murmurs
RS : BAE + , crepts +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left sided pneumonia ( ?TB )
- prerenal AKI
- bilateral fixed flexion deformity since 2 yrs
P :-
1) IVF 0.9 %NS IV @ 100 ml / hr
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS
4) Inj . Dexa 6 mg IV / TID
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd
hrly
11 ) physiotherapy was done
4/1/2023 :
Bed 6
Day 7
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S :
Stools not passed since 3 days
O :Pt is C/C/C
BP :100/70 mm of Hg
PR : 120 bpm
RR :18 / min
Temp : 98 F
Spo2 : 98 % at RA
GRBS : 167 mg / dl
I/O : 2600/1050
CNS :- GCS : E4V1M1
Right. Left
Tone :- UL hypo hypo
LL hypo hypo
Power :- UL and LL : not moving even with pain
Reflexes B/L: biceps , triceps , supinator , ankle , knee :-not elicited
Brain stem reflexes :-
B/L corneal + ,conjuctival + , pupillary + ,
Doll's eye : absent on left
Gag :+
Plantar b/L : mute
CVS : S1 , S2 heard, no murmurs
RS : BAE + , expiratory fine crepts + in right and left infraaxillary areas
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left sided pneumonia ( ?TB )
- prerenal AKI
- bilateral fixed flexion deformity since 2 yrs
P :
1) IVF 0.9 % 2 units NS, 1 unit RL IV @ 100 ml / hr
2) Nebulization with inpravent - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS
4) Inj . Dexa 6 mg IV / TID
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd
hrly
11 )passive physiotherapy
12) syp .Lactulose 15 ml RT /BD
13) inj .Lasix 40 mg IV/ stat
5/1 /2023
ICU
Bed 6
Day 8
Unit 3
Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 )
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern)
S:
Stools passed in morning
O :
Patient is conscious , oriented to person , not oriented to place , time
BP :110/70 mm hg
PR :- 117 bpm
RR : 17 cpm
Temp : 98 F
Spo2 : 98 % at RA
GRBS :- 188 mg/dl
I/O : 3150/1400 ml
CNS :- GCS : E4V4M1
Right. Left
Tone :- UL hypo hypo
LL hyper hyper
Power :- right left
UL. 0/5 2/5
LL. 0/5. 0/5
Reflexes:- not elicited
CVS : S1 , S2 heard, no murmurs
RS : BAE + , crepts +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's
- Prerenal AKI
- B/L fixed flexion deformity since 2 yrs
P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr
- Nebulization with duolin - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg PO/OD
- syp lactulose 15 ml RT / BD
- Inj .Thiamine 200 mg IV/BD in 100 ml NS
- Inj . Dexa 4 mg IV / TID
- ATT therapy PO/OD FDC:3 tab/ day
- RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
- vitals monitoring 6 th hrly
- passive physiotherapy
6/1 /2023
S:
No fresh complaints
O :
Patient is conscious , oriented to person , not oriented to place , time
BP :110/70 mm hg
PR :- 78 bpm
RR : 17 cpm
Temp : 98 F
Spo2 : 98 % at RA
GRBS :- 139 mg/dl
I/O : 2000/1450 ml
In
CNS :- GCS : E4V4M6
Right. Left
Tone :- UL Normal normal
LL normal normal
Power :- right left
UL. 0/5 4/5
LL. 0/5. 0/5
Reflexes:- not elicited
CVS : S1 , S2 heard, no murmurs
RS : BAE + , NVBS +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's
- Prerenal AKI
- B/L fixed flexion deformity since 2 yrs
P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr
- Nebulization with duolin - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg PO/OD
- syp lactulose 15 ml RT / BD
- Inj .Thiamine 200 mg IV/BD in 100 ml NS
- Inj . Dexa 4 mg IV / TID
- ATT therapy PO/OD FDC:3 tab/ day
- RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change
7/1/23
S:
No fresh complaints
No bed sores
No fever spikes
Passed 2 stools
c/o hiccups
O :
Patient is conscious , oriented to person and place
BP :120/80 mm hg
PR :- 115 bpm
RR : 20 cpm
Temp : 97.0 F
Spo2 : 98 % at RA
GRBS :- 86 mg/dl
I/O : 2100/1350 ml
CNS :- GCS : E4V5M6-15/15
Left Right.
Tone :- UL N Hypo
LL N Hypo
Power :- Left Right
UL. 3/5 0/5
LL. 2/5 0/5
Reflexes:- not elicited
CVS : S1 , S2 heard, no murmurs
RS : BAE + , NVBS +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's
- Prerenal AKI (resolving)
- B/L fixed flexion deformity since 2 yrs
P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr
- Nebulization with ipravent - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg RT/OD
- syp lactulose 15 ml RT / BD
- Inj .Thiamine 100 mg IV/BD in 100 ml NS
- ATT therapy RT/OD FDL : 3 tabs/ day
- RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change
Investigations:
RFT and LFT :
Fever chart
SOAP NOTES
8/1 /2023
ICU
Bed 6
Day 11
Unit 3
S:
No bed sores , no fever spikes , stools passed
O :
Patient is conscious , oriented to person , not oriented to place , time
BP :110/70 mm hg
PR :- 78 bpm
RR : 17 cpm
Temp : 98 F
Spo2 : 98 % at RA
GRBS :- 82 mg/dl
I/O : 2500/1050 ml
CNS :- GCS : E4V5M6
Right. Left
Tone :- UL hypo normal
LL hypo normal
Power :- right left
UL. 0/5 3/5
LL. 0/5. 2/5
Reflexes:- not elicited
CVS : S1 , S2 heard, no murmurs
RS : BAE + , NVBS +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's
- Prerenal AKI
- B/L fixed flexion deformity since 2 yrs
P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr
- Nebulization with duolin - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg PO/OD
- syp lactulose 15 ml RT / BD
- Inj .Thiamine 200 mg IV/BD in 100 ml NS
- Inj . Dexa 4 mg IV / TID
- Tab .Talvopton 15 mg PO/OD
- ATT therapy PO/OD FDC:3 tab/ day
- RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change
9/1 /2023
S:
No fresh complaints
No bed sores
No fever spikes
Stools not passed
c/o hiccups
O :
Patient is conscious , oriented to person and place
BP :120/70 mm hg
PR :- 100 bpm
RR : 20cpm
Temp : 97.2 F
Spo2 : 98 % at RA
GRBS 84mg/dl
I/O : 2100/1350 ml
CNS :- GCS : E4V5M6-15/15
Left Right.
Tone :- UL N Hypo
LL N Hypo
Power :- Left Right
UL. 3/5 0/5
LL. 2/5 0/5
Reflexes:- not elicited
CVS : S1 , S2 heard, no murmurs
RS : BAE + , NVBS +
P/A:- soft , non tender
A :-
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's
- Prerenal AKI (resolving)
- B/L fixed flexion deformity since 2 yrs
- Hyponatremia ? SIADH
P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr
- Nebulization with ipravent - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg RT/OD
- syp lactulose 15 ml RT / BD
- Inj .Thiamine 100 mg IV/BD in 100 ml NS
- ATT therapy RT/OD FDL : 3 tabs/ day
Tab Isoniazid 75mg
Tab Rifampicin 150mg
Tab pyrazinamide 400mg
Tab ethambutol 275mg
- RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
- Tab Tolvaptan 30mg PO/OD
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change
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