59 K. Rithika Vasantha

Greetings to one and all who are currently reading my blog. This is Rithika, a third semester 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 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. 

Note :  This e-log is done under the guidance of Dr. Jancy mam. 

A 60 YEAR OLD MALE WITH ALTERED SENSORIUM UNDER EVALUATION

Chief complaints:

• Fever since 2-3 days, associated with generalized weakness. 

•  Irrelevant talk and drowsiness since 1 day

History of present illness:

• Patient was apparently asymptomatic, 3 days back. 

• From the past 3 days, he developed fever, associated with generalized weakness

• Also has history of irrelevant talk and drowsiness since 1 day

• Has history of binge drinking  , since 4-5 days, without eating. 

• Has no history of headache, cough, vomiting 

History of past illness:

• Has history of rt. femur fracture due to fall from a bike 6 months back. 

• Similar complaints like the above, due to his habit of excessive drinking

Treatment history:

•  Has undergone a surgery for right femur

• Has no treatment history of DM, HTN, CAD, asthma, stroke, blood transfusion, TB, hormones, antibiotics, chemoradiation. 

Personal history:

• Pt is married and is farmer by occupation. 

• His appetite is normal, and follows a mixed diet. 

• Has regular bowel habits and normal micturition

• Has no known allergies

• He's an alcoholic, consumes alcohol regularly, since 40 yes

• Has an habit of smoking chutta since 40 yrs, 4-5 per day

Family history:

• Has no family history of DM, HTN, TB, asthma, cancers, stroke, heart diseases

Physical Examination:

• Has no pallor, no cyanosis, no lymphadenopathy, no clubbing of fingers/toes, no oedema of feet, no malnutrition and no dehydration

• Icterus - present

Systemic Examination:

A. Cardiovascular system

• No thrills and no cardiac murmurs

B. Respiratory system

• No dyspnoea, and no wheeze present

• Central position of trachea is present

• Vesicular breathing sounds present

C. Abdomen 

• Shape of abdomen - obese

• Tenderness - present at right hypochondriac and epigastric regions

• Has no palpable mass, bruits, free fluids

• Liver and spleen are not palpable

• Bowel sounds - heard

• Hernial orifices - normal

D. Central Nervous system

• No neck stiffness and no kerning's sign

Provisional diagnosis:

ALTERED SENSORIUM,UNDER EVALUATION

            SECONDARY TO ALCOHOLIC INTOXICATION, UTI, PNEUMONIA

Investigations :

On 10.8.21

1. ECG

2. Ultrasound report 

On 11.8.21

LDH - 1,175.8 IU/L

HCV - positive

Treatment :

On 10.8.21

• IVF 10 NS with 2 ampules thiamine/IV

• INJ. PAN 40 mg/IV / BD

• INJ. Optineuron 1 ampule in 10 NS/IV/OD

• Head end elevation

• Inj. Neomol 1gm/IV infusion

• T. PCM 650 mg

• Monitor BP, PR ,  RR

• Strict I/O charting

• Tepid sponging and temperature charting 4th hourly

• O2 inhalation @ 15L/min to maintain SPO2 >95%

• IVF - 0.9% NS - Continuous infusion @ 75ml/hr

• Nebulization with BUDECORT /6th hourly

• T. ODILIV 150 mg /BD

• Syp. LACTULOSE 10ml/BD

DEATH SUMMARY:

• On 11.8.2021 , at 1:30 pm, patient started having tachypnoea with respiratory rate of 44 cpm, and hypoxia ( type 1 respiratory failure) 

• Patient suddenly developed weakness of right upper limb and right lower limb with blood pressure of 110/80 mmHg and worsening GCS :  E1 V1 M1

• On suspicion of CVA : IC bleed / acute infarct - CT brain was done which showed no significant abnormalities

• Patient was intubated in v/o poor GCS and falling saturations. 

           But pt had bradycardia and was asystolic for which CPR was initiated according to the aha guidelines, 2015 ; yet pt couldn't be revived and ECG showed no electrical activity and pt was declared dead at 7:36 pm on 11/8/2021

• Immediate cause of death :

Type 1 respiratory failure secondary to pneumonia

? Aspiration / infective etiology

Antecedent cause of death :

?  Acute infarct involving brain stem

Alcoholic delirium

Acute viral hepatitis Hep C

? Alcoholic hepatitis