5 A vignesh

GENERAL MEDICINE CASE PRESENTATION

●INTRODUCTION 

A 45 yr old male is chronic alcoholic since 20 yrs carpenter by occupation was brought to causality in a state of altered sensorium since 1 day.

•CHIEF COMPLAINTS 

•Difficulty in walking&decreased appetite since 15 days

•Constipation since 5 days

•Fever and pedal edema since 3 days

•Vomiting since 2 days

•HISTORY OF PRESENT ILLNESS

•Patient was apparently asymptomatic 6 months 

Back until he had b/l pedal edema.he has diagnosed with hypothyroidism 

•Patient had difficulty in walking and decreased appetite since then.

•H/o constipation since 5 days.

•Fever - low grade , intermittent , releived with treatment since 3 days.

•B/l pedal edema - pitting , extending upto knees since 3 days.

•Vomiting - non bilious , non projectile , associated with food particles since 2 days.

•Altered sensorium since 1 day.

•Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD/TB

•HISTORY OF PAST ILLNESS 

•1.5 month back he had history of fever,dry cough&weight loss from then

•1 month back he had tingling&numbness in b/l lower limbs till ankle later he diagnosed as peripheral neuropathy,patient had difficulty in walking and decreased appetite since then

•TREATMENT HISTORY 

•He was on T.Thyronorm 25mcg for hypothyroidism 

•PERSONAL HISTORY 

•HE is chronic alcoholic since 20 yrs

•FAMILY HISTORY 

•No familiar history 

•GENERAL EXAMINATION 

•Patient was in altered sensorium 

•Moderately built and moderately nourished

•No Icterus and pallor

•B/l pedal edema

•No lymphaedenopathy 

O/E

12/07/21

•Pt was in altered sensorium 

•Not oriented to T/P/P

•GCS:-E2V2M4

13/07/21

•E2V1M4
•TEMP 98.4°F

14/07/21

•E2V2M4 
•Temp 98.4 ° F
•Anisochoria&sluggish reacting to pupil

15/07/21

•E4V4M4

16/07/21

•E1V1M1

•VITALS

12/07/21

PR:86 BPM

BP:90/50 mmhg

Spo2:-98% on RA

13/07/21

BP 120/90 mmhg

PR -92/min

Spo2 91 % on RA

14/07/21

BP 120/90 mmHg
PR 85/min
Spo2 -85% on RA
Spo2-95% on 4 lit

15/07/21


•BP :-110/90 mmHg
•PR:-120/min
•spo2-90% on RA
          -95% on 4 lit

16/07/21
•BP :- 80/60 mmhg
•PR -114/min
•spo2-80% on RA
          -96% on 4lit o2

CVS

12/07/21

S1 S2 + ,no murmurs

RS:BSE+,NVBS

P/A:Soft,NT

13/07/21

S1s2 +
RS:-B/LAE +
Rt side wheeze in IMA,IAA
P/A-soft

14/07/21

S1S2 +
RS-B/LAE +
P/A - soft

15/07/21

•S1s2
RS-B/LAE +
P/A-soft

16/07/21

•s1s2
•B/LAE +
•P/A -soft

CNS

12/07/21

Neck stiffness+

Tone:

Hypotonia in b/l LL

Power

Left UL 3/5

Left LL 1/5 

Right UL &LL 0/5

Reflexes:

2+,plantar:withdrawl

13/07/21

Cns               Rt        Lf
Tone- UL      N        N
            LL     hypo   hypo

Power-UL  moving both UL
              LL       -

Reflexes B    ++        ++
                 T   +            +
                 S    +            +
                 K    +           +
                 A    +           +
                 P     +           +

14/07/21 

Cns                          RT                LT
  Tone - UL              N                  N
              LL             hypo           hypo

Power -UL         moving both UL
              LL                    --

Reflexes   B       ++                ++
                   T        +                  +
                   S         +                  +
                   K         +                  +
                   A         -                    -
                    P   withdrawl 

15/07/21

                         Rt             lt
Tone -UL        hypo     hypo 
          -LL         hypo    hypo
Power -UL        -             -
              UL        -             -
Reflexes
              B           +            +
              T           +            +
              S           +            +
              K          +            +
              A           +            +
             P       withdrawl 

16/07/21
                        Rt              lt
Tone- UL       hypo         hypo
           LL        hypo        hypo

Power - UL      -                -
               LL      -                -

Reflexes
              B          +                +
              T           +                +
              S           +                 +
              K           +                 +
              A           -                   -
              P          withdrawl

INVESTIGATIONS 

12/07/21

CBP


CUE



APTT



PROTHROMBIN TIME


TROPONIN 1



BLOOD SUGAR RANDOM


SERUM ELECTROLYTES(Na,k,cl)


ABG


BLOOD UREA 


CREATININE


LIVER FUNCTION TEST



REPORT



CHEST RADIOGRAPHY



MRI


●CSF analysis 


INVESTIGATIONS ON 13/07/21


LIVER FUNCTION TEST 



CSF ANALYSIS 






BACTERIAL CULTURE AND SENSITIVITY REPORT




CYTOLOGY 


HIV TEST


HCV TEST

C REACTIVE PROTEIN

HBsAg



2D ECHO



REPORT

RADIOLOGY




INVESTIGATIONS ON 14/07/21

S.ELECTROLYTES 


BLOOD UREA

HEMOGRAM 


S.CREATININE 


REPORT



PROVISIONAL DIAGNOSIS

•Meningitis-bacterial/TB
•CVA(embolic infarcts in B/L cerebral hemisphere)
•Hyponartemia
•Chronic nutritional hypoalbunemia
 13/7/21
Coronary artery disease 
HFIEF(EF 42%)

TREATMENT 

12/07/21

1)Inj CEFTRIAXON 2gm × IV ×BD
             1-×-1
2)Inj DEXMETHASONE 8mg×IV × BD
             1-×-1
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)TAB PCM 650mg ×RT ×sos

13/07/21


1)Inj CEFTRIAXON 2gm × IV ×BD
2)Inj DEXMETHASONE 8mg×IV × BD
3)INJ PAN 40gm × IV × OD
4)IVF NS 100 ml/hr
5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD
7)temp charting 4th hrly
8)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day
                                         100mg-1/day
9)TAB ASPIRIN 150mg × RT×OD
10)TAB ATORVAS 40 mg ×RT ×OD


14/07/21


1)Inj CEFTRIAXON 2gm × IV ×BD
2)Inj DEXMETHASONE 8mg×IV × BD
3)FLUID RESTRICTION  1.5 lit /day
4)RT feeds 
   100ml milk & 3 to 4 scoops protein powder -4th hrly
 100ml  free water -2nd hrly
5)INJ PAN 40gm × IV × OD
6)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
7)Inj OPTINEURON 1 amp in 100 ml NS/IV×OF
8)IVF 3% Nacl @ 10ml/hr
9)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day
                                         100mg-1/day
10)TAB ASPIRIN 150mg × RT×OD
11)TAB ATORVAS 40 mg ×RT ×OD
12)TAB TOLVAPTAN 15 mg × RT × OD
13)TAB THYONORM 25 MCG × RT × OD
14)NEBULISATION  
           ipravent -6th hrly
           Budecort  6th hrly
           mucomist  6th hrly
15) oral suction 2nd hrly
16) position  change 2nd hrly
17)TAB BENADON plus 40mg ×RT ×OD

15/07/21

1)RT feeds 
   100ml milk & 3 to 4 scoops protein powder -4th hrly
2)IVF 3%Nacl @100ml /hr
3)FLUID restriction <5 lit /day
4)Inj CEFTRIAXON 2gm × IV ×BD
5)Inj DEXMETHASONE 8mg×IV × BD
6)INJ PAN 40gm × IV × OD
7)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
8)Inj OPTINEURON 1 amp in 100 ml NS/IV×OF
9)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day
                                         100mg-1/day
10)TAB ASPIRIN 150mg × RT×OD
11)TAB ATORVAS 40 mg ×RT ×OD
12)TAB TOLVAPTAN 15 mg × RT × OD
13)TAB THYONORM 25 MCG × RT × OD
14)NEBULISATION  
           ipravent -6th hrly
           Budecort  6th hrly
           mucomist  6th hrly
15) oral suction 2nd hrly
16) position  change 2nd hrly
17)TAB BENADON plus 40mg ×RT ×OD

16/07/21

1)RT feeds 
   100ml milk & 3 to 4 scoops protein powder -4th hrly
2)IVF 3%Nacl @100ml /hr
3)FLUID restriction <5 lit /day
4)Inj CEFTRIAXON 2gm × IV ×BD
5)Inj DEXMETHASONE 8mg×IV × BD
6)INJ PAN 40gm × IV × OD
7)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD
8)Inj OPTINEURON 1 amp in 100 ml NS/IV×OF
9)T.ISONIAZID -300 mg - 1 tab/day
    T.RIFAMPSIN -600 mg-2 tab/day
     T.PYRIZINAMIDE-1500 mg -2 tab/day
     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day
                                         100mg-1/day
10)TAB ASPIRIN 150mg × RT×OD
11)TAB ATORVAS 40 mg ×RT ×OD
12)TAB TOLVAPTAN 15 mg × RT × OD
13)TAB THYONORM 25 MCG × RT × OD
14)NEBULISATION  
           ipravent -6th hrly
           Budecort  6th hrly
           mucomist  6th hrly
15) oral suction 2nd hrly
16) position  change 2nd hrly
17)TAB BENADON plus 40mg ×RT ×OD




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