short case
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
Feb 6,2022
A 50 year male farmer ,manual labourer,brought to casualty with h/o altered sensorium since 1 day
H/o fever since 4 days.
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 4 days ago,then he developed fever which is high grade,No diurnal variation, associated with chills.
No h/o cough and GE symptoms.
Attenders tells h/o stoppage of OHA for 3days, h/o decreased intake of food as he has fever.
H/o altered sensorium since 1 day.
Irrelevant talk,not recognising attenders since this morning .
Able to move all four limbs,No h/o vomitings, head ache, seizures.
SHIFTED HERE FOR FURTHUR MANAGEMENT.
PAST HISTORY -
H/o TB 2YRS back used ATT for 6 months.
Diagnosed as Type -2 Diabetes mellitus on OHA 1 YR back.
No H/O HTN,CVA,CAD,COVID-19.
PERSONAL HISTORY :
DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR ,
BLADDER MOVEMENTS - REGULAR, ADDICTIONS-H/O SMOKING 30yrs ago(1 pack per day)-
ALCOHOL-REGULAR INTAKE OF 180ML SINCE 30YRS,STOPPED SINCE 2YRS AFTER DIAGNOSIS OF TB.
RECENTLY ALCOHOL INTAKE ON JAN 15,2022.
FAMILY HISTORY:Non-significant.
TREATMENT HISTORY: on OHA SINCE 1YS.
ON ATT FOR 6MONTHS.
ON EXAMINATION -
PATIENT IS CONCIOUS , INCOHERENT NON COOPERATIVE
NO ICTRUS
NO PALLOR
CLUBBING: absent
NO CYANOSIS , NO LYMPHADENOPATHY, NO EDEMA
VITALS -
TEMPERATURE - 97' F
PULSE RATE - 126BPM
BLOOD PRESSURE - 190/80 MM OF HG
RESPIRATORY RATE - 28
SPO2 - 97 % AT ROOM AIR
GRBS-HIGH.
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM :
BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
DYSPNOEA PRESENT.
P/A - soft,non tenderness
, no organomegaly
CNS:
Pt is conscious, inorientation ,non cooperative
HMF: couldnot be elicited.
Motor system:unable to move right LL against gravity.
Tone - Rt Lt
U/L N N
L/L ?HYPO N
Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.
B/L PLANTAR EXTENSION PRESENT.
O/E NECK STIFFNESS PRESENT,APPEARS TO BE ?SPONDYLOARTHROPATHY.
INVESTIGATIONS:
On 6/2/22
TREATMENT :
1.IVF 2 UNITS NS IV_BOLUS/STAT.
AND THEN IVF NS@100ML/HR
2.INJ.HAI 6U/IV/STAT
3.INJ.HUMAN ACTRAPID 1ML(40U)
4.INJ.THIAMINE 1AMP IN 100ML NS/IV/OD
5.INJ.OPTINEURON 1 AMP IN 100ML NS/IV/OD
6.GRBS MONITORING-EVERY HOURLY.
7.INJ.MONOCEF 2GM/IV/BD.
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