61 year old chronic alcoholic with altered sensorium

Mallannagari.Srilekha roll number:77
                9th semester 
This is online E log book to discuss out patients de-identified health data shared after taking his guardian`s 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 patients clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome.

A 61year old male who is farmer by occupation and chronic alcoholic came to causality with altered sensorium since one week 
History of presenting illness 
The patient was apparently asymptomatic one week back had done his work in the farm and came home ate dinner and went to sleep as usual and had an episode of involuntary movements of all limbs with uprolling of eyes , froth from mouth, involuntary micturition , tongue biting , shortness of breath and abdominal tightness. There was post ictal confusion for three days .patient was admitted in a hospital in Hyderabad with above complaints . Later he started removing his cannula, oxygen mask and started on tab. LIBRIUM 

Past history:
history of left CVA 6 years back 
6 years back patient had giddiness in the morning  and weakness of upper limb and lower limb of the left side recovered with in 15 days .according to reports infarct in lacunar area.
Patient was diagnosed with hypertension in 2016 for which he is on medication (not regular)
Denovo type 2 Diabetes Mellitus 
Not a known case of, TB, asthma, 
Personal history:
Diet mixed
Appetite normal 

Bowel and bladder regular

No known allergies

 Chronic Alcoholic since 20 years 

No significant family history.

GENERAL EXAMINATION:
Patient is drowsy but arousable 

Pallor no

Icterus no

Cyanosis no

Clubbing no 

Lymphadenopathy no 

Edema no 

Vitals 

Pulse rate 94bpm, regular , normal volume.

Blood pressure 120/80 mmHg measured  in right arm

Respiratory rate18 cpm

Temperature afebrile

Systemic examination:

CVS:S1 and S2 heart sounds heard.

No murmurs heard

RESPIRATORY SYSTEM

Position of the trachea central

BAE present , vesicular breath sounds heard

Bilateral Crepitations On auscultation.

ABDOMINAL EXAMINATION

Palpation: liver and spleen not palpable and no palpable masses.

Hernial orifices are free.

No free fluid no bruits 

bowel sounds heard 

CNS EXAMINATION:

Patient is drowsy but arousable 
Speech is slurred
Eyes are medically deviated 
Motor
Power.  UL     LL
       Rt 3/5.     3/5
    Left. 3/5.      3/5
Tone increased on all limbs
Reflexes  B.     T.       S.     A.      K.        P
   Right.  2+.      +.      +.     3+     3+     Extension
    Left.    2 +.    +.      +      3+      3+    Extension

Investigations: 













Provisional diagnosis: 
seizures secondary to intracranial bleed, ATYPICAL PNEUMONIA ?aspiration pneumonia


TREATMENT:
Head end elevation 
O2 inhalation to maintain saturation >94
Tab CLINDAMYCIN 300 mg RT/TID
Tab PARACETAMOL 659 mg RT/TID
Tab STAMLO 5mg OD
Tab LEVIPIL 500mg RT/TID
Tab PULMOCLEAR OD
Inj. LEVOFLOXACIN 500mg IV OD
Tab PREGABALIN OD
Nebulisation with IPRAVENT 2nd hourly 
                             BUDECORT 4th hourly
Frequent change of posture 
Chest physiotherapy 
Ryle tube feeds 100 ml water 2 hourly and 200ml milk +protein powder 4th hourly.

Case discussion video link

Comments

Post a Comment

Popular posts from this blog

Prefinal paper-1

Image
Q1)define acute kidney injury. Etiology and clinical features of acute kidney injury.write a brief note on diagnosis and management of aki. Q2)what are types of diabetes mellitus?diagnosis and treatment of type 1 and 2 diabetes mellitus. Q3)write a brief note on pneumonia  Q4)write a short note on cholelithiasis. Q5)post streptococcal glomerulonephritis. Q 6)write a note on hypopituitatism.  Q7)chronic myeloid leukaemia. Q8)hepatic encephalopathy and it’s treatment. Q9)pulmonary function tests Q10)indications of dialysis  Q11)beta thalasemia  Q12)disease modifying drugs in RA Q13)anti snake venom  Q14)what is serum Ascitis albumin gradient. Q15)difference between Crohn’s disease and ulcerative colitis. Q16)causes of lymph edema.
Read more

A 48 year male with viral pneumonia due to COVID

Image
 Mallannagari.Srilekha Roll No:- 77 MBBS 8th-Sem  This is online E log book to discuss out patients de-identified health data shared after taking his guardian`s 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 patients clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome.       A 48 YEAR OLD MALE WITH CHIEF COMPLAINTS OF COUGH AND SHORTNESS OF BREATH SINCE 2 DAYS  CAME TO HOSPITAL ON 17TH OF MAY    HISTORY OF PRESENT ILLNESS The patient was apparently asymptomatic 2days back , then developed cough and shortness of breath. Cough is sudden in onset, continues in nature and aggravated on sleep. Shortness of breath is present on daily activities also(GRADE 4).  Patient was tested positive fo...
Read more

50 year old male with viral pyrexia

Image
 Mallannagari.Srilekha roll.no:77 9th semester  This is online E log book to discuss out patients de-identified health data shared after taking his guardian`s 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 patients clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome. A 50 year old male came to the opd with  Chief complaints of : fever since 3 days  Cold and cough since 3 days  History of presenting illness: The patient was apparently asymptomatic 3 days back and then he had fever which is of high grade and associated with cills and rigors  Cough since 3 days which is sudden in onset and productive with mucoid nature. Not associated with shortness of breath. Cold since 3 days. No history of chest pa...
Read more