50 year old man with altered sensorium, pain in abdomen and fever

 

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A 50 year old male resident of Miryalaguda, farmer by occupation came to the casualty in a stuporous  state with complaints of  pain in the abdomen since 3 weeks, loss of appetite since 10 days, history of vomitings since 3 days and fever since 3 days. 




HISTORY OF PRESENTING ILLNESS -


Patient was apparently asymptomatic 15 days ago, when he developed pain in abdomen in the epigastric region following an episode of alcohol intake the previous night, associated with 3 episodes of vomitings-food particles as content. Fever was insidious in onset and gradually progressive.


PAST HISTORY - 

No similar complaints in the past.

Not known case of DM, HTN,CVA,CAD, epilepsy.

He tested positive for COVID-19 on Day 2 of admission.

He was diagnosed with DENGUE (by IgM test) 6 days prior to admission.


PERSONAL HISTORY :

Diet- mixed

Appetite- loss of appetite since 10 days 

BOWEL - CONSTIPATION SINCE 3 DAYS

Bladder- regular 

ADDICTIONS-

        H/O smoking since the past 30-35 years (2-3 bidis per day)

        ALCOHOL- Regular intake of alcohol since the past 30-35 years  (90-180ml consumption of whiskey )


FAMILY HISTORY: Not significant.


TREATMENT HISTORY: Not Significant


 ON EXAMINATION -


Patient is drowsy and not cooperative.

ICTRUS -PRESENT

Pallor, clubbing, cyanosis, lymphadenopathy, edema- absent  

VITALS - 

TEMPERATURE - 102°F

 PULSE RATE - 98BPM

BLOOD PRESSURE - 130/80 MM OF HG 

RESPIRATORY RATE - 22

SPO2 - 98% AT ROOM AIR

 

GRBS:132MG/DL

GCS-E3V2M4

PUPILS:NSRL


SYSTEMIC EXAMINATION - 


CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS


RESPIRATORY SYSTEM : 

BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS


P/A - soft, no tenderness 

, no organomegaly


CNS: 

Pt is DROWSY,NO RESPONSE,

non cooperative 

Neck STIFFNESS+

kernig sign+.


Motor system:


Tone  -   Rt      Lt


U/L        N          N

L/L        N       N            

    

Investigations:






USG ON DAY 1 of ADMISSION 

1.SURFACE IRREGULARITY WITH ALTERED ECHO TEXTURE OF LIVER.

2.GB WALL EDEMA

3.MILD ASCITIS.


LFT: 

TB-8.95                                                     

DB-3.85 

AST-64

ALT-190

ALP-319

TP-4.7

ALB-2.77

A/G-1.44

PT-20

INR-1.4

APTT-38


RFT: UREA-49,CREAT-0.9,URIC ACID-2.8,CA++-7.7,K+-2.9,CL-96,Na-140


CUE-NORMAL       

              

SEROLOGY:NEGATIVE 


ABG: suggestive of RESPIRATORY alkalosis may be due to anxiety.

pH-7.51

pCO2-27

pO2:85.5

HCO3:21.2

LACTATE:3.50

Opthamology referral was done.


Findings in left eye:

Lids-discharge at canthus

Conjunctiva- early inflammed nasal pterygium

Mild congestion +

Cornea-clear

Sclera-yellowish discoloration +




PROVISIONAL DIAGNOSIS: ?DENGUE ENCEPHALITIS 


TREATMENT:


1.IVF-NS,RL@100ML /HR

2.INJ.MONOCEF 1 GM /IV/BD

3.INJ.ZOFER 4MG/IV/TID

4.INJ.THIAMINE 2 AMP IN 100ML NS/IV/STAT

5.INJ.NEOMOL 1 GM/IV/STAT

6.TAB.PCM 650MG/PO/TID

7.SYP.LACTULOSE 20ML/PO/TID

8.PROCTOLYTIC ENEMA-P/R-TWICE DAILY

9.INJ.DOXYCYCLIN E 100MG/IV/BD

10.INJ.VIT K 10MG IV_OD

11.INJ.PAN 40 MG /IV/BD




Day-1 ICU BED-2


soap notes.


50YEAR/male



S-C/O ALTERED SENSORIUM AND FEVER


O-


O/E:Icterus-present

        No pallor/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema

Temp:96.1

PR:75bpm

BP:140/80 mm of hg

RR:24cpm

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard

P/A:SOFT,NONTENDER



A- ?DENGUE ENCEPHALITIS 


P-


1.IVF-NS,RL@100ML /HR

2.INJ.MONOCEF 1 GM /IV/BD

3.INJ.ZOFER 4MG/IV/TID

4.INJ.THIAMINE 2 AMP IN 100ML NS/IV/STAT

5.INJ.NEOMOL 1 GM/IV/STAT

6.TAB.PCM 650MG/PO/TID

7.SYP.LACTULOSE 20ML/PO/TID

8.PROCTOLYTIC ENEMA-P/R-TWICE DAILY

9.INJ.DOXYCYCLIN E 100MG/IV/BD

10.INJ.VIT K 10MG IV_OD

11.INJ.PAN 40 MG /IV/BD




LP DONE.










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