A 75 yr old male with altered sensorium

 This is an online E-Log book to discuss our patient's de-identified data shared after taking his/her/Guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

CASE:

A 75 years old diabetic male came to casualty with c/o altered sensorium.

CHIEF COMPLAINTS:

Unresponsiveness and difficulty in breathing since previous night.

HOPI:

Patient was apparently asymptomatic before the previous evening, he had his dinner and slept. Around midnight he made some sounds ( like snoring) and had involuntary movements for 2minutes and was unconscious and unresponsive.

Altered sensorium of sudden onset.

No h/o tongue bite, involuntary micturition.

No h/o previous seizures.

No h/o of vomiting and  headache.

PAST HISTORY:

No similar complaints in past.

He is a k/c/o of Diabetes since 10 years and is on medication for the same. (? unknown)

Not a k/c/o HTN, CVA, CAD, TB, EPILEPSY, ASTHMA.

PERSONAL HISTORY:

1. Diet- Mixed
2. Appetite- Normal
3. Bowel and bladder movements- Regular
4. Sleep- Adequate
5. Addictions- H/o alcohol consumption occasionally which hestopped 3years ago; cigarette smoking for 15years stopped 3 years ago.
6. Surgical history-No h/o previous surgeries.

FAMILY HISTORY:

Not significant.

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.

The patient is unconscious.

He is well nourished and moderately built.

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

No signs of malnutrition/ dehydration.

VITALS:

1. Temp-102°F
2. PR-111bpm
3. RR-20cpm
4. BP-140/80mmHg 
5. SpO2-98% on 14L O2
6. GRBS- 329mg/dL

SYSTEMIC EXAMINATION:

1. CVS- S1, S2 Heard
2. RS- BAE+, BARREL shaped chest present, B/L crepts heard in all lung fields.
3. P/A-  scaphoid, non tender, no organomegaly.
4. CNS-

• Level of consciousness- COMA
• GCS- E1M1V1
• Pupil are mid dilated, unresponsive to light.
• Gag reflex PRESENT
• Neck stiffness PRESENT.
• REFLEXES-   LEFT            RIGHT

1. Biceps               2+                  2+ 
2. Triceps.            2+                   2+
3. Supinator        2+                   2+
4. Knee.                 1+.                 1+
5. Ankle                2+.                  2+
6. Plantar.         Withdrawal     Mute

INVESTIGATIONS:

HEMOGRAM

PROTHROMBIN TIME

KETONE BODIES

COMPLETE URINE EXAMINATION

HEPATITIS C

HEPATITIS B

ARTERIAL BLOOD GASES

HIV

RANDOM BLOOD SUGAR

RENAL FUNCTION TEST

GLYCATED HEMOGLOBIN

SERUM ELECTROLYTES

APTT

LIVER FUNCTION TEST

ECG

CT BRAIN

PROVISIONAL DIAGNOSIS:

Hypodensity of bilateral Cerebellar and Brainstem with ? VIRAL MENINGITIS, ? AKI 2° to SEPSIS, ? Aspiration Pneumonia, ? consolidation.

TREATMENT:

7/11/2021

1. IVF- NS and RL @ 75ml/hr
2. Inj. PIPTAZ 4.5g IV STAT then 2.25 IV/QID
3. Inj. NEOMOL 1g IV/SOS (if temperature>101°F)
4. Inj. PAN 40mg IV/OD
5. Inj. ZOFER 4mg IV/TID
6. Inj. OPTINEURON 1amp in 100ml ND IV/OD
7. RT feeds-2nd hourly (3 scoops protein powder+ 150ml milk)
8. ET/Oral suctioning- 3 hourly
9. Inj. MIDAZ - 1mg/kg/hr (~60kg);                            no dilution- 1mg-1ml                                  1.2ml-6ml/hr(max dose)
10. Inj. LEVIPIL 500mg IV/BD
11. Air/ water bes
12. Change of position every 2nd hourly
13. DVT stockings

8/11/2021

1. IVF- NS and RL @ 75ml/hr
2. Head end elevation upto 30°
3. Inj. NEOMOL 1g IV/SOS (if temperature>101°F)
4. Inj. OPTINEURON 1amp in 100ml ND IV/OD
5. Inj. PAN 40mg IV/OD
6. Inj. ZOFER 4mg IV/TID
7. Inj. LEVIPIL 500mg IV/BD
8. Inj. DEXA 4mg/IV/BD
9. Inj. ACYCLOVIR 500mg IV/TID
10. RT feeds-2nd hourly (free water-100ml + protein powder-100ml)
11. ET/Oral suctioning- 3 hourly
12. Strict I/O charting- 2nd hourly
13. BP, PR , SpO2 charting- hourly
14. Inj. CEFTRIAXONE 2g/IV/BD
15. Inj. MANNITOL 100mL/IV/BD

9/11/2021

1. IVF- NS and RL @ 75ml/hr
2. Head end elevation upto 30°
3. Inj. NEOMOL 1g IV/SOS (if temperature>101°F)
4. Inj. OPTINEURON 1amp in 100ml ND IV/OD
5. Inj. PAN 40mg IV/OD
6. Inj. DEXA 4mg/IV/BD
7. Inj. ACYCLOVIR 500mg IV/TID
8. RT feeds-2nd hourly (free water-100ml + protein powder-100ml)
9. ET/Oral suctioning- 3 hourly
10. Inj. CEFTRIAXONE 2g/IV/BD
11. Inj. MANNITOL 100mL/IV/BD
12. Strict I/O charting- 2nd hourly
13. BP, PR , SpO2 charting- 4thhourly