General Medicine

A 75 year old male with Altered sensorium 

03,September, 2022.
E LOG GENERAL MEDICINE 

Hi, I am Pindi Gayatri, 3rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 those patient's 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 the comment box is welcome.”

I've 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.

CHIEF COMPLAINTS 
A 75 year old male came to casuality with the chief complaints of fever since 1 month and irrelevant talking since 10 days.

HISTORY OF PRESENT ILLNESS 
Patient is apparently normal 10 days ago then he developed high grade fever which was not associated with chills and rigors. Then he developed altered sensorium. since 5 days he was not able to recognize his family members. 
No nausea,no vomitings, no loose stools. 

HISTORY OF PAST ILLNESS 
No history of hypertension, Diabetes mellitus, Tuberculosis, epilepsy  etc.
Has hypopigmented patches on bilateral lower limbs and bilateral nipples since 10 years (using herbal medication regularly-unknown).Itching is present. 

TREATMENT HISTORY 
No Diabetes, hypertension, CAD,Asthma, Tuberculosis, antibiotics, hormones, chemo/Radiation, blood transfusion, surgeries. 

PERSONAL HISTORY 
Married 
Occupation-
Appetite-normal 
Diet-mixed
Bowels-regular 
Micturition-normal 
No known allergies 
Habits/addictions- alcohol-occasional
                          Tobacco smoking
                No betel leaf and betel nut usage 
     
FAMILY HISTORY 
No Diabetes, hypertension, heart disease, stroke, cancers, tuberculosis, asthma. 

GENERAL EXAMINATION 
No pallor 
No icterus 
No cyanosis
No clubbing of fingers 
No lymphadenopathy 
No edema of feet 
No micturition 
VITALS
Temperature-101°F
Pulse rate-92/min
Respiratory rate-20 cpm
Blood pressure-120/70mmHg (left arm).
SpO2 at room air-98%
GRBS-132mg%

SYSTEMIC EXAMINATION 
CVS
No thrills
S1S2 sounds heard 
No cardiac murmurs 
RESPIRATORY SYSTEM 
Position of trachea-central 
Vesicular breath sounds heard 
No dyspnea 
No wheeze 
ABDOMEN
Shape of the abdomen-scaphoid 
No tenderness 
No palpable masses
Normal hernial orifices 
No free fluid 
No bruits
Non palpable liver
Non Palpable spleen
Bowel sounds are heard
CNS
Level of consciousness- Drowsy 1 arousable
Speech- incoherent 
               Incomprehensible sounds.
Signs of meningeal irritation 
         stiffness of neck :yes
          Kerning's sign:positive
Cranial nerves,motor system, sensory system-can't be elicited
Glassgow scale-E3V1M6

Reflexes
            Biceps Triceps supinator  knee  ankle 
Right       -             -             -              -           -      
Left         -             -              -             -           -  
Plantars-flexor 

PROVISIONAL DIAGNOSIS 
Altered sensorium  under evaluation 

INVESTIGATIONS 
                               ECG
On 3rd, September 
                               ECG

RECORDINGS 
                     TPR GRAPHIC SHEET 

TREATMENT 
11.Azithromycin -500mg oD

DIAGNOSIS 
Altered sensorium 2°to ?alcohol withdrawal 
                                        ?Meningoencephalitis
Fever under evaluation 

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