1801006072 short case

 This is 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 patients 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 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 diagnosis and treatment plan

CHIEF COMPLIANTS

A 64 year male patient presented with cheif compliants of:

Cough since 10 days

Loose stools since 10 days

Hiccups since 7 days

Inability to speak since 4 days 

fever 4 days back

loss of appetite since 3 days

HISTORY OF PRESENT ILLNESS

patient was apparently asymptomatic 10 days back then he developed diarrhoea -5 episodes/day for 1 day which relieved on medication.Then he developed having hiccups since 7 days and anorexia for 3days.since 25/12/22 he is unable to talk.

        

PAST HISTORY

h/o panic attack one month back secondary to family issues 

  -DM2 since 6 yrs ,

 on medication :tab Metformin OD , tab Glimiperide OD

 -NO HISTORY OF HTN, TB, Asthma, epilepsy, CAD, CVD

Personal History :- 

Appetite - reduced

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements - incontinence 

Addictions: Occasional alcoholic ( during functions ) ,chews tobacco daily

Allergies : No allergies 

Family history:

Mother is a known case of TB 5years back who is treated adequately.

GENERAL EXAMINATION

Patient is unconscious ,incoherent , uncooperative

 Moderately Built and Moderately Nourished .

Pallor : present 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent

 Vitals :- 

Temp: Afebrile 

BP : 100 / 50 mmHg 

PR : 120 bpm 

RR : 16 cpm 

SPO2 : 98 % at RA

GRBS : 193 mg/dl 

Fever 

SYSTEMIC EXAMINATION: 

CNS examination :-

HIGHER MENTAL FUNCTIONS

State of consciousness : unconscious 

Speech : incoherent 

Sensory system :- 

Pain - Normal 

Temp - normal

Cranial nerves :  

Not elicited patient not cooperative

CNS 

Reflexes :-

Biceps + +

Tricep s + +

Supinator + +

Knee +

Ankle. ++

Flexor. Plantar. Plantar 

Finger nose in coordination - no 

Heel knee in coordination - no

CVS : S1 S2 + ,no murmurs ,no thrills 

Respiratory System : decreased air entry on left side . Crackle sound are heard. Position of trachea - central.

Per abdominal examination:- 

Soft , non tender , no signs of organomegaly

Chest X-ray 

INVESTIGATIONS:

CSF ANALYSIS

Sugar  51 mg/dl (normal 60-90mg/dl)

Protein 203mg/dl( normal 10- 45mg/dl)

Chloride 121 mmol/L (116-127mmol/l)

CSF CELL COUNT

Colour - colour less

Appearance - slightly cloudy

Total cells - 90 cells /cumm

Lymphocytes -60%

Neutrophils - 40%

COMPLETE URINE EXAMINATION

Colour - pale yellow

Appearance - clear

Reaction - acidic

Specific gravity - 1.010

Albumin -nil

Sugar -nil

Bile salts - nil

Bile pigments- nil

Pus cells - 2-3cells(normal 0-5/HPF)

Epithelial cells- 2-3 cells(normal 0-5HPF)

RBC -nil (normal 0-5/HPF)

Crystals-nil

Casts-nil

Amorphous deposits-absent

BLOOD UREA -124mg/dl(normal 17-50mg/dl)

APTT

  

APTT TEST- 31sec(normal 24- 33sec)

Bleeding and clotting time

Bleeding time- 2min 30sec(normal2 -7 min)

Clotting time- 5min (normal 1- 9min)

PROTHROMBIN TIME - 15sec ( normal 10 -16 sec)

MRI BRAIN PLAIN 

DIFFUSE CEREBRAL ATROPHY

BLOOD SUGAR 159mg/dl 

DIAGNOSIS 

    Altered sensorium secondary to tuberculous

meningitis 

Management:-

1) IVF 0.9 %NS IV @ 50 ml / hr 

2) Inj , 1 amp Optineuron in 500 ml NS IV /OD 

3) tab Ecosprin AV 75/10 RT / OD / HS

4) GRBS monitoring 6 th hrly 

5) Inj Thiamine 200 mg IV/BD in 100 ml NS