Pt does hotel management and stays alone.
He was apparently asymptomatic 5 days back. He had fever 5 days back which was high grade, continuous, associated with chills and rigors. No history of cold and cough . He went to local hospital got treated but the fever did not subside.
Later after a day he consumed beer, had biryani.
He had 1 episode of vomiting and loose stools since 3 days. (2 days back), while he was in room suddenly he had involuntary movements of all 4 limbs associated with frothing, uprolling of eyes, post ictal confusion, he bit his lower lip no tongue bite . He had 1 episode of vomiting at the time of involuntary movement, and loose stools.
Loose stools, foul smelling.
Since yesterday afternoon, pt was in altered sensorium , with slurred speech, and deviation of mouth.
He presented to hospital on 19/09/22 and was treated he was sedated at 1am was sent home at 4:30am . He woke up at 2pm . He had altered sensorium and involuntary movements.
No c/o weakness of upper limb and lower limb.
No h/o cough, cold, palpitations, syncopal attacks, chest pain
PAST HISTORY
N/k/c/o - DM, HTN, EPILEPSY,TB , ASTHMA
FAMILY HISTORY
No significant history
PERSONAL HISTORY
appetite- normal
Diet- mixed
Bowel and bladder - normal
Sleep- regular
Habits - alcohol consumption occasionally,
Smoking
General examination:
On examination:
Pt is in altered sensorium
No pallor, Icterus, clubbing, cyanosis lymphadenopathy, edema
VITALS
BP 110/60mmHg
PR 110bpm
Temp. 100°F
CVS S1, S2 +
RS - BAE +, NVBS
CNS EXAMINATION:
NERVOUS SYSTEM EXAMINATION
a. Conscious
b. Not Oriented to time, place and person
c. Speech and language –no aphasia, dysarthria, dysphonia
d. Memory – immediate-retention and recall, recent and remote - not intact
MOTOR examination
Meningeal signs
Kernigs sign +
Brudzinski sign -
Power:
Rt. Lt
UL +4/5. -4/5
LL. +4/5. -4/5
Tone
UL. N N
LL. N. N
Hand grip: 100%. 100%
Provisional Diagnosis: MODS (Meningoencephalitis, Hepatitis & Glomerulonephritis) due to ? Systemic Vasculitis associated with ? Rickettsial Spotted Fever ? Viral Hemorrhagic Fever ? HUS/TTP
Investigations
21/09/22
PT 16SEC
INR 1-11 SEC
Hemogram
Urinary electrolytes
CUE
Urine protein /creatinine ratio
23/09/22
Treatment
21/09/22
1)IVF NS , RL @100ML/hr
2)INJ. ZOFER 4MG IV/SOS
3)INJ. THIAMINE 200MG IN 100ML NS/IV/TID
4)STRICT I/O CHARTING
5)BP/PR/RR/SPO2 2nd Hrly.
22/9/22
O/E
Patient was agitated, talking to self, irritable
BP- 120/90 mmHg
PR - 96bpm
CVS- S1 S2 +
RS- BAE+ , NO ADDED SOUNDS
P/A- SOFT
A: ALTERED SENSORIUM UNDER EVALUATION 2° TO ? DENGUE ENCEPHALITIS WITH PRE RENAL AKI WITH VIRAL HEPATITIS.
P
IVF NS, DNS @70ml/hr
INJ. ZOFER 4mg/IV/SOS
INJ. THIAMINE 2OO mg in 100 ml NS IV/TID
STRICT I/I CHARTING
SYP. DUPHALAC 15ML PO/TID
TAB DOXY 100 mg/ RT/BD
24/09/22
S: agitated, non co-operative
O:
Pt concious
Temp : 98.7
BP: 140/90mmHg
PR - 72bpm
CVS S1 S2 +
RS - BAE+
P/A- soft, tender
GCS- E4V5M6
A: altered sensorium under evaluation 2° dengue encephalitis with pre-renal AKI (resolved)
with viral hepatitis with alcohol withdrawal syndrome with MODS
P:
1) IVF NS,DNS @75 ml/hr
2) INJ.DOXY 100mg/IV/BD
3) INJ. DEXA 8mg/IV /TID
4) INJ. THIAMINE 200mg in 100ml NS/IV/BD
5) SYP. DUPHALAC 30ml PO/TID
6) STRICT I/O CHARTING
7) BP/PR/SPO2 MONITORING 2ND HRLY.
25/09/22
ICU bed 4
21year old male
S: sensorium improved
Fever spikes+
O:
Pt concious
Temp : 100.7
BP: 140/90mmHg
PR - 70bpm
CVS S1 S2 +
RS - BAE+
P/A- soft, tender
GCS- E4V5M6
A: altered sensorium under evaluation 2° ? TTP
? Viral encephalitis with renal AKI (glomerulonephritis)
with viral hepatitis with MODS.
P:
1) IVF NS,DNS @75 ml/hr
2) INJ.DOXY 100mg/IV/BD
3) INJ. DEXA 8mg/IV /TID
4) INJ. THIAMINE 200mg in 100ml NS/IV/BD
5) SYP. DUPHALAC 30ml PO/TID
6) STRICT I/O CHARTING
7) BP/PR/SPO2 MONITORING 2ND HRLY.
26/9/22
S:Sensorium improved
No fever spikes
O: Pt is conscious,coherent
Cooperative
BP-110/90
Pr-76
Temp-98.1f
CVS-S1S2+
P/A -soft,NT
Spo2-95%
A:ALTERED SENSORIUM UNDER EVALUATION secondary to ?TTP with pre-renal AKI(resolved)
with viral hepatitis with alcohol withdrawal syndrome with MODS
P:Plan for treatment
1.Plenty of oral fluids
2.INJ DOXY 100mg/IV/BD
3.INJ DEXA 8mg/IV/BD
4.INJ THIAMINE 200mg in 100mlNs/IV/OD
5.SYP DUPHALAC 30ml PO/TID
6.Strict I/O charting
