42 year old male with altered sensorium and fever

This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning. 

DEIDENTIFICATION - 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CASE DISCUSSION -

Patient was brought to the hospital with chief complaints of 

altered sensorium since yesterday and fever since yesterday

HOPI:

Patient was apparently asymptomatic 3 years back,then he started sleep taking at night time with shouting in between ,also abuses his wife gets angry for small reasons,used to abuse his coworkers also near work place.

This continued till last Sunday,then patient was taken to Hyderabad(rehabilitation centre) on last Sunday and was admitted there after which he was normal for 4 days and then since Friday started abusing everyone.

From today morning he was in altered sensorium and was drowsy and was brought to a hospital.

Complaints of fever since yesterday which is insidious gradually progressive not associated with chills and rigor.No aggrevating factors and relieved with medication.

PAST H/O:

Not a K/C/O DM, HTN, THYROID, ASTHMA, EPILEPSY.

PERSONAL HISTORY:

• Marital status-Married
• Occupation- Farmer
• Diet: mixed
• Appetite: normal
• Bowel and bladder : Normal
• Addictions:Alcoholic since 20 years(increased intake since 10 years

FAMILY HISTORY:

No similar complaints in the family.

GENERAL EXAMINATION:

• Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
• he is drowsy.
• Built & nourishment-Moderate
• No pallor 
• No cyanosis
• No icterus
• No clubbing
• No edema
• No lymphadenopathy.

SYSTEMIC EXAMINATION:

CVS : 

• S1 S2 present
• No murmurs

RESPIRATORY SYSTEM:

• B/l symmetrical chest
• Trachea - Central
• B/l air entry present
• NVBS heard

ABDOMEN:

• Shape of abdomen: scaphoid.
• Soft, non tender, no organomegaly present.
• No rigidity or guarding.

CNS :

• Patient is conscious
• Speech-normal 
• Signs of meningial irritation
• Neck stiffness- negative
• Kernings sign-negative
• Cranial nerves-intact

Motor system:

• Power:

            R. L

UL. 5/5. 5/5

LL. 5/5. 5/5

 

• Tone:

           R. L

UL. Normal. Normal

LL. Normal normal

Sensory system: normal

Reflexes:

    Knee. Ankle. Biceps. Triceps supinator

• Right 2+. 1+. 2+ 1+. 1+
• Left. 2+. 1+. 2+ 1+ 1+
• Plantar flexion seen.
• No cerebellar signs

TREATMENT:

1.IV FLUIDS NS @50ML/HR

2.INJ.THIAMINE 100MG IN 100 ML NS IV/TID

3.INJ.OPTINEURON 1AMP IN 100ML NS I /OD

4.INJ.NEOMOL 1GM IV/SOS

5.TAB.SDOLO 650 MG PO/SOS