Case of 42/M, with ALTERED SENSORIUM.

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NAME: MEGHANA.M
ROLLNO: 90 
2017 BATCH 


CASE DETAILS

HISTORY: 
   
   A 42 yr old male, farmer by occupation, was brought to the casualty with chief complaints of altered sensorium, vomitings and fever since 2 days and was unresponsive since 2 days.
On evaluation, his GCS was E1V1M4.


HOPI:

Patient presented with complaints of 2 episodes of vomitings, 2 days back, with food as it's contents, and sudden in onset (?PROJECTILE).
The episode was preceded by hiccoughs.
Following the episode, he had frothing and spasm of neck muscles (?TONIC POSTURE), and loss of consciousness.

Vomitings were associated with fever with chills and rigors.
No history of pain abdomen, loose stools, cold cough. 
He apparently lost his speech.


PAST HISTORY: 


Patient had similar complaints in the past, with nearly 8-10 episodes of vomitings at night, 1 month back, sudden in onset, non bilious, non projectile, non blood tinged, contents being food,
History of alcohol consumption prior to vomiting.(10/9/2021)
Treated by RMP, with I.V fluids, condition improved.

Symptoms recurred 2 days later( 12/9/21)

Followed by involuntary movements of the upper and lower limbs associated with frothing and loss of consciousness. (?GTCS) 
(FIRST EVER SEIZURE EPISODE) on 12/9/21 night.
Post ictal confusion present.
Associated with fever ,chills and rigors. 


He was taken to a private hospital, managed conservatively and he IMPROVED and gained consciousness after 2 days. (Treated as DYSELECTROLYTEMIA.)

No history of loss of speech.

History of UTI during hospital admission which was resolved.

Started deteriorating 3-4 days later (18/9/2021).. 
Adviced to get an MRI, therefore shifted to our hospital on 18/9/2021, 4pm.

Patient also had back pain 1yr back, following a fall at his workplace under the influence of alcohol, due to which he was asked to stop consumption of alcohol because of jaundice.
Patient stopped working because of generalized weakness since 1 year.


History of ALCOHOL WITHDRAWAL SYMPTOMS.  (Tremors and cravings)
No known history of DM, HTN, asthma, epilepsy, TB. 


His past history can be more extensively viewed here: 




PERSONAL HISTORY:

Diet:             Mixed
Appetite:     Decreased
Sleep:          Decreased
Bowel and bladder movements regular.
Addictions: WHISKEY, 150, ONCE WEEKLY,                                 since 15 years
                     Stopped 1 year ago, (Apparantly)
                     PAN (ZARDA) chewing everyday.                             Since 15 years.
                     No history of smoking.
Allergies:.   No known food or drug allergies.

GENERAL EXAMINATION:
Patient was drowsy, but arousable.
Afebrile, 
BP: 100/60 mm Hg
PR: 92 bpm
RR: 20 cpm
SpO²: 99% on RA

Pallor: absent
Icterus: absent
Clubbing: absent
Cyanosis: absent
Lymphadenopathy: absent
Edema: absent

Respiratory system: Bilateral air entry +
Cardiovascular system: S1 S2 heard.
Per abdomen: soft, non tender, no scars or                                      sinuses, bowel sounds present.
CNS examination: 
                          He is drowsy, with loss of speech, GCS E1V1M4. 
Motor power:.    UL.         LL
   R                      3/5         3/5
   L                      3/5         3/5

Tone increased in all 4 limbs.

Reflexes:.     
           B     T     S     A    K     P
    R.   2+   2+   2+  2+   2+   Extensor
    L.   2+   2+   2+  2+   2+   Extensor

 Signs of meningeal irritation: 
                                  KERNIG'S POSITIVE

Doll's eye sign: PRESENT


INVESTIGATIONS:

ECG:



Rate: 100-110 bpm
Rhythm: Regular sinus rhythm
Axis: Normal axis

T wave inversions present in precordial leads

MRI BRAIN: 

    
     No abnormality detected in brain.

SERUM ELECTROLYTES:

Past values:


On 26/9:
Serum Chloride: 90
             Sodium: 132
             Potassium: 4.1








Patient was discharged on 26/9/21


Re-admission:

On 1/10/21:
Serum chloride: 182
             Sodium: 142
             Potassium: 16.4

On 2/10/21:
Serum chloride: 94
             Sodium: 125
             Potassium: 4.8
On 3/10/21:
Serum chloride: 98
             Sodium: 132
             Potassium: 4.2


On 4/10/21:
Serum chloride: 98
             Sodium: 131
             Potassium: 4.2


Ophthalmology referral: 

No signs of raised ICT present after complete evaluation


Past psychiatry referral:

Alcohol abstinence from 1 year
Lapse on 10/9/21, consumed 12 units of alcohol. 
Based on this, it HIGHLY UNLIKELY FOR THE SEIZURES TO BE DUE TO ALCOHOL WITHDRAWAL. 
Rule out neurological causes.

Present ophthalmology, psychiatry and surgery referral: 


















PROVISIONAL DIAGNOSIS: 

Euvolemic hypoosmolar Hyponatremia,
(?SIADH)
? Bacterial/ TB meningitis


TREATMENT:




SOAP NOTES DAY 3
Subjective-
No fever spikes

Objective
On examination : 
Pt is c/c/c
Oriented to t/p/p
patient is able to talk and started oral feed 
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy

Vitals:
TEMP 98.2F
PR: 90 bpm, regular
RR: 15cpm
BP: 110/80 mmHg 
SPO2:
AT ROOM AIR-99%
GRBS:101mg/dl
Systemic examination :
 CVS:S1,S2 heard
 Apex beat:5th ICS
Resp:
BAE+(vesicular breath sounds)
Nvbs heard
Position of trachea- central
P/A: soft, tenderness absent, bowel sounds heard
Cns: No focal deficit
HMF+
SPEECH-NORMAL
MEMORY-intact
No meningeal signs
Pupils-NS RL
MOTOR
Power-(4/5 4/5)
Tone-(Normal in all 4 limbs)
Reflexes-
     B T S A K P 
R 2+ + - + + flexion
 L 2+ + - + + flexion

Assessment-

Altered sensorium secondary to ? Hyponatremia(resolved)
with alcohol withdrawal seizure(resolved)
With pyrexia secondary to UTI
No fever spikes 
 
Plan of care-
 head end elevation 
inj levipil 800mg in bd
inj optineuron 1amp 
inj monocef 2 lgm iv
inj Vancomycin 500mg in 200ml NS
Inj Neomol 1gm iv sos 
tab pcm 650mg 
tab tolvapt 15mg
double strength Ors 
monitoring vitals 4th bourly 
.Monitor vitals-4rth hourly
  I/O charting



Link to my case presentation: 

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