65yr old presented with altered sensorium

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

CASE :

A 65 yr old male, farmer by occupation and having 4 sons and 1 daughter, resident of nalgonda visited casualty with
C/o fever since 1 week, Altered sensorium since yesterday and also has c/o 1 episode of vomiting today morning

Patient was apparently asymptomatic 1 week ago then he developed fever which is high grade, intermittent and associated with chills for which he went to local RMP and used medications but symptoms didn't subside.
Patient had h/o cough since 1 week associated with scanty sputum, not blood tinged. Fever associated with loss of appetite and generalised weakness.
Burning micturition was present
No h/o pain abdomin and loose stools
No h/o headache, loss of consciousness, seizures, trauma
He has no h/o diabetes mellitus, hypertension, asthma, epilepsy, tuberculosis
He had a h/o - ? Hemodialysis 6years ago ( ? AKI ) i/v/o fever and generalized anasarca
No further usage of medication
He is an occasional alcoholic and his last drink was 1 week back
He is also a smoker, smokes 1 pack/day

On examination
Patient was drowsy but arousable with irrelevant talking
Pallor present
No icterus, cynaosis, clubbing, lymphadenopathy, edema

VITALS :
Temp - 97.5 F
BP - 110/70 mmhg
PR - 93 bpm
RR - 22 cpm
SpO2 - 98 %

CVS - S1 S2 heard
RS - BAE present , B/L diffuse rhonci present,
Right Infrascapular areas coarse crepts present
Per Abdomen - tenderness on palpation in right hypochondrium
CNS -
GCS - E4 V2 M5
Neck stiffness present
Patient moving all limbs on painful stimulus
Pupils - Rt - reacting to light
              Lt - sluggish reaction to light
Reflexes :
                      Right         Left
Biceps            +2             +1
Triceps           +1             +
Supinator        -                -
Knee               +1             +1
Ankle               -                -
Planter            withdrawal

Provisional diagnosis :
  Fever with altered sensoo secondary to ?uraemic ENCEPHALOPATHY with chronic renal failure
? meningitis


INVESTIGATIONS :

ABG
pCO2 - 19.8
pO2 - -
SpO2 - 95.7%
St HCO3 - 9.9
HCO3 - 7

Hemogram
Hb - 8.8 gm/dl
TLC - 9100
PLT - 2.5
RBC - 2.6

Blood grouping and typing - B positive

Malaria parasite - negative

Dengue serology - negative

RBS - 90

RFT
Blood urea - 284
Sr. Creatinine- 9.7
Sr. Na - 141
Sr. K - 4.2
Sr. Cl - 101

Serology  ( HbsAg, HIV, HCV ) - negative

USG
- B/L grade 2 RPD with right simple Renal cortical cyst
- Cholelithiasis 

Chest X ray PA view 

ECG 
u



Treatment
Day 0
- Propped up posture
- IVF - NS & RL @ 100ml /hr
- Inj. Neomol 1g/ IV / SOS (if temp >101 F )
- INJ. OPTINEURON 1 Amp in 1 NS / IV / OD
- INJ. PAN 40 mg IV OD
- INJ. ZOFER 4 mg / IV / BD
- Neu. with DUOLIN 8th hourly and BUDECORT 12th hourly
- INJ. CEFTRIAXONE 2g IV BD
- TAB. PCM 650 mg / PO / TID 

After taking ophthalmology referral to r/o raised intracranial pressure features for doing Lumbar puncture and was cleared for doing LP
On doing Lumbar puncture, 
CSF CYTOLOGY showed 5 cells


Patient underwent hemodialysis (1)


Day 1 

- Propped up posture
- Inj. Neomol 1g/ IV / SOS (if temp >101 F )
- INJ. OPTINEURON 1 Amp in 1 NS / IV / OD 50ml/hr
- INJ. PAN 40 mg IV OD
- INJ. ZOFER 4 mg / IV / BD
- Neu. with DUOLIN 8th hourly and BUDECORT 12th hourly
- INJ. CEFTRIAXONE 2g IV BD
- TAB. PCM 650 mg / PO / TID 

Patient underwent hemodialysis (2)

Day 2

- Propped up posture
- Inj. Neomol 1g/ IV / SOS (if temp >101 F )
- INJ. OPTINEURON 1 Amp in 1 NS / IV / OD 50ml/hr
- INJ. PAN 40 mg IV OD
- INJ. ZOFER 4 mg / IV / BD
- Neu. with DUOLIN 8th hourly and BUDECORT 12th hourly
- INJ. CEFTRIAXONE 2g IV BD
- TAB. PCM 650 mg / PO / TID

Patient underwent hemodialysis (3)

Day 3 

- Propped up posture
- Inj. Neomol 1g/ IV / SOS (if temp >101 F )
- INJ. OPTINEURON 1 Amp in 1 NS / IV / OD 50ml/hr
- INJ. PAN 40 mg IV OD
- INJ. ZOFER 4 mg / IV / BD
- Neu. with DUOLIN 8th hourly and BUDECORT 12th hourly
- INJ. CEFTRIAXONE 2g IV BD
- TAB. PCM 650 mg / PO / TID

Patient underwent hemodialysis (4)

Day 4

- Propped up posture
- Inj. Neomol 1g/ IV / SOS (if temp >101 F )
- INJ. OPTINEURON 1 Amp in 1 NS / IV / OD 50ml/hr
- INJ. PAN 40 mg IV OD
- INJ. ZOFER 4 mg / IV / BD
- Neu. with DUOLIN 8th hourly and BUDECORT 12th hourly
- INJ. CEFTRIAXONE 2g IV BD
- TAB. PCM 650 mg / PO / TID

Patient underwent hemodialysis (5)

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