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

 

This is an online E log book to discuss our patient's de-identified health 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 those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 


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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