45 yr old male patient with altered sensorium.

B.Shradha
Roll no -10
8 th semester
Under the guidance of Dr.Selina Maam (Intern)
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have 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 a diagnosis and treatment plan.
 
A 65 yr old male pateint Came in a drowsy state,with chief complaints of -
Fever - high grade , Intermittent associated with chills 

# HISTORY OF PRESENTING ILLNESS:
*Patient was apparently Asymptomatic 6 days back then he developed 
*VOMITINGS- 1-5 episodes per day, non bilious,Non projectile ,Non blood tinged,
For which he went to government hospital and got treated.
*Prior to vomiting patient had a history of intake of alcohol(360ml).
*4 days back He had history of Involuntary movements both in Upper and lower Limbs- 1 episode ,which is associated with froathing and tongue bite .
*Patient was Unconscious during episode and was  taken to a private hospital and treated conservatively.
*2 days back patient was in drowsy state ,talking , conscious and coherent developed fever associated with chills.

# PAST HISTORY:
*Patient stopped working 1 year ( becoz of generalised weakness).
*2 months back there was back pain used (pain killers).
*Not a k/c/o  Hypertension,Asthma ,TB,CAD
*No h/o past surgeries.
# FAMILY HISTORY:
*Not significant.
# PERSONAL HISTORY:
*DIET - mixed
*APEPTITE-Normal.
*BOWEL AND BLADDER MOVEMENTS-Regular
*ADDICTIONS-H/o Alcohol consumption since 15 years.(weekly thrice)
*H/o Smoking Beedi since - 15 years( daily one pack).
# GENERAL EXAMINATION:
*Patient is drowsy on admitted day from next day he is conscious, coherent.
Moderately build and well nourished.

*Temperature- Febrile.(100°F)=>(99°F)=>(98°F)
*Bp-90/60 mmHg=>100/70mmHg=>120/80mmHg.
*Pulse- 99 bpm.
*GRBS-80 mg/dl
*Pallor -Absent
*Icterus-Absent 
*Cyanosis-Absent
*Lymphadenopathy-Absent.
#SYSTEMIC EXAMINATION:
*CVS- S1& S2 present.
*CNS - Intact.
*RESP- BAE +,NVBS
*P/A - soft & non tender.
*CNS- HME (+)
Speech - normal
Memory- Intact.
MOTOR SYSTEM-
POWER:- Rt.        Lt
  UL.       4/5.      4/5
  LL.        4/5.      4/5
TONE:-Normal in all 4 limbs.
REFLEXES:- B.  T. S. A. K. P
      Rt.         2+. +. - +.   +.  Flexion
      Lt.         2+. +. - +.   +.  Flexion
#PROVISIONAL DIAGNOSIS:-
ALTERED SENSORIUM SECONDARY TO HYPONATREMIA.
ALCOHOL WITHDRAWAL.
#INVESTIGATIONS:-
*On 18-09-2021-

*ON 19-09-2021
*ON 20-09-2021
*On 18-09-2021
URINE - Na+ =298.       Serum - Na+= 130
               K+.  =12.3.                   K+ =4.5
               Cl-.  =381.                   Cl - =92
*On 19-09-2021
SERUM - Na+  =127
              K+   =3.6
              Cl-. = 97
*On 20-09-2021
SERUM - Na + = 132
             K+    = 3.9
             Cl-.  = 99
*On 21-09-2021
SERUM - Na + =133
              K+.   = 4.0
              Cl-   = 97
              
*ECG :-
On 18-09-2021
On 19-09-2021
 *X- Ray:-
On 24/09/2021-

*USG REPORTING:-(24-09-2021)
#HEMOGRAM( ON 25-09-2021)


#TREATMENT:-
On 19-09-2021
RT feeds -100ml milkwith protein powder                          +100ml water.
IV fluids 0.9%NS @150ml/ hr+ RL
INJ.pantop 40 mg IV/OD
INJ.zofer 4mg IV /SOS
INJ.Thaimine 100mg IV /TID
INJ .levipil 50mg IV / BD
INJ Ceftriaxone 2gm/IV/BD
Bp/PR/temp charting -4 hrly
I/o charting.
 
On 20-09-2021
IV fluids 0.9%NS @150ml/ hr+ RL
INJ.pantop 40 mg IV/OD
INJ.zofer 4mg IV /SOS
INJ.Thaimine 100mg IV /TID
INJ .levipil 50mg IV / BD
INJ Ceftriaxone 2gm/IV/BD
Monitor vitals 4hrly
GRBS 4 hrly
INJ Lorezepam -2cc/IV/sos

On 21-9-2021
IV fluids 0.9%NS @150ml/ hr+ RL
INJ.pantop 40 mg IV/OD
INJ.zofer 4mg IV /SOS
INJ.Thaimine 100mg IV /TID
INJ .levipil 50mg IV / BD
INJ Ceftriaxone 2gm/IV/BD 
INJ Lorezepam-2cc IV/sos
TAB DOLO 650 mg po/TID
INJ Neomol 100mg IV /sos
Monitor vitals 4 hrly
Temp & I/o charting
GRBS 6 hrly charting

On 22-09-2021.
IV fluids 0.9%NS @150ml/ hr+ RL
INJ.pantop 40 mg IV/OD
INJ.zofer 4mg IV /SOS
INJ.Thaimine 100mg IV /TID
INJ .levipil 50mg IV / BD
INJ Ceftriaxone 2gm/IV/BD
INJ Lorezepam-2cc IV/sos
TAB DOLO 650 mg 
Monitor vitals
Temp charting& I/o charting
GRBS -6 th hrly.

Thank you Selina maam for the guidance.
Thank you Dr.Rakesh Biswas sir for the opportunity






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