01 HARIKRISHNA

              GENERAL MEDICINE

12.JULY.2021

INTRO: This is an online E-LOG recorded to discuss and analyse our patient's health data and history shared after his/her guardian's signed and informed consent..

CASE SHEET: 

A 45 year old male chronic alcoholic, carpenter by occupation came to the OPD with< altered sensorium..

CHIEF COMPLIANTS:

                                      ~Difficulty in walking&decreased appetite.

                ~Fever and pedel edema.

HISTORY OF PRESENT ILLNESS:

  *State of altered sensorium since 1 day

  *Patient had difficulty in walking and decreased appetite since       then.

  *H/o constipation since 5 days.

  *Fever - low grade , intermittent , releived with treatment since    3days.

  *B/l pedal edema - pitting , extending upto knees since 3 days.

  *Vomiting - non bilious , non projectile , associated with food       particles since 2 days.

  *Altered sensorium since 1 day.

  *Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD/TB

  HISTORY OF PAST ILLNESS:

         

       *1.5 month back he had history of fever,dry cough & weight loss         from then.

    *1 month back he had tingling & numbness in b/l lower limbs till       ankle and 15days later he was admitted in our hospital with           those c/o tingling & numbness in b/l lower limbs till ankle           associated with slippage of footwear.

    *Patient was apparently asymptomatic 6 months back until he had       b/l pedal edema for which he went to a local hospital where he       was diagnosed with hypothyroidism.

  

  HISTORY OF PAST MEDICATIONS:

                                    >  T.Thyronorm 25mCg for HYPOTHYROIDISM.

      PERSONAL HISTORY:

                *CHRONIC ALCOHOLIC since 20 years..

   FAMILIAL HISTORY:

                    * Not specific 

   

   GENERAL EXAMINATION:

                       >Altered sensorium since 1 day.

          >Fever and pedal edema.

          >Moderately built and moderately nourished

           >No Icterus and pallor

           >B/l pedal edema

     VITALS:

12/07/21

PR:86 BPM

BP:90/50 mmhg

Spo2:-98% on RA

13/07/21

BP 120/90 mmhg

PR -92/min

Spo2 91 % on RA

14/07/21

BP 120/90 mmHg

PR 85/min

Spo2 -85% on RA

Spo2-95% on 4 lit

15/07/21

•BP :-110/90 mmHg

•PR:-120/min

•spo2-90% on RA

          -95% on 4 lit

16/07/21

•BP :- 80/60 mmhg

•PR -114/min

•spo2-80% on RA

          -96% on 4lit o2

CVS

12/07/21

S1 S2 + ,no murmurs

RS:BSE+,NVBS

P/A:Soft,NT

13/07/21

S1s2 +

RS:-B/LAE +

Rt side wheeze in IMA,IAA

P/A-soft

14/07/21

S1S2 +

RS-B/LAE +

P/A - soft

15/07/21

•S1s2

RS-B/LAE +

P/A-soft

16/07/21

•s1s2

•B/LAE +

•P/A -soft

CNS

12/07/21

Neck stiffness+

Tone:

Hypotonia in b/l LL

Power

Left UL 3/5

Left LL 1/5 

Right UL &LL 0/5

Reflexes:

2+,plantar:withdrawl

13/07/21

Cns               Rt        Lf

Tone- UL      N        N

            LL     hypo   hypo

Power-UL  moving both UL

              LL       -

Reflexes B    ++        ++

                 T   +            +

                 S    +            +

                 K    +           +

                 A    +           +

                 P     +           +

14/07/21 

Cns                          RT                LT

  Tone - UL              N                  N

              LL             hypo           hypo

Power -UL         moving both UL

              LL                    --

Reflexes   B       ++                ++

                   T        +                  +

                   S         +                  +

                   K         +                  +

                   A         -                    -

                    P   withdrawl 

15/07/21

                         Rt             lt

Tone -UL        hypo     hypo 

          -LL         hypo    hypo

Power -UL        -             -

              UL        -             -

Reflexes

              B           +            +

              T           +            +

              S           +            +

              K          +            +

              A           +            +

             P       withdrawl 

16/07/21

                        Rt              lt

Tone- UL       hypo         hypo

           LL        hypo        hypo

Power - UL      -                -

               LL      -                -

Reflexes

              B          +                +

              T           +                +

              S           +                 +

              K           +                 +

              A           -                   -

              P          withdrawal

 

INVESTIGATIONS 

12/07/21

CBP

CUE

APTT

PROTHROMBIN TIME

TROPONIN 1

BLOOD SUGAR RANDOM

SERUM ELECTROLYTES(Na,k,cl)

ABG

BLOOD UREA 

CREATININE

LIVER FUNCTION TEST

REPORT

CHEST RADIOGRAPHY

MRI

●CSF analysis 

INVESTIGATIONS ON 13/07/21

LIVER FUNCTION TEST 

CSF ANALYSIS 

BACTERIAL CULTURE AND SENSITIVITY REPORT

CYTOLOGY 

HIV TEST

HCV TEST

C REACTIVE PROTEIN

HBsAg

ECH2DO

REPORT

RADIOLOGY

INVESTIGATIONS ON 14/07/21

S.ELECTROLYTES 

BLOOD UREA

HEMOGRAM 

S.CREATININE 

REPORT

PROVISIONAL DIAGNOSIS

•Meningitis-bacterial/TB

•CVA(embolic infarcts in B/L cerebral hemisphere)

•Hyponartemia

•Chronic nutritional hypoalbunemia

 13/7/21

Coronary artery disease 

HFIEF(EF 42%)

TREATMENT 

12/07/21

1)Inj CEFTRIAXON 2gm × IV ×BD

             1-×-1

2)Inj DEXMETHASONE 8mg×IV × BD

             1-×-1

3)INJ PAN 40gm × IV × OD

4)IVF NS 100 ml/hr

5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD

6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD

7)temp charting 4th hrly

8)TAB PCM 650mg ×RT ×sos

13/07/21

1)Inj CEFTRIAXON 2gm × IV ×BD

2)Inj DEXMETHASONE 8mg×IV × BD

3)INJ PAN 40gm × IV × OD

4)IVF NS 100 ml/hr

5)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD

6)Inj OPTINEURON 1 amp in 100 ml NS/IV/OD

7)temp charting 4th hrly

8)T.ISONIAZID -300 mg - 1 tab/day

    T.RIFAMPSIN -600 mg-2 tab/day

     T.PYRIZINAMIDE-1500 mg -2 tab/day

     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day

                                         100mg-1/day

9)TAB ASPIRIN 150mg × RT×OD

10)TAB ATORVAS 40 mg ×RT ×OD

14/07/21

1)Inj CEFTRIAXON 2gm × IV ×BD

2)Inj DEXMETHASONE 8mg×IV × BD

3)FLUID RESTRICTION  1.5 lit /day

4)RT feeds 

   100ml milk & 3 to 4 scoops protein powder -4th hrly

 100ml  free water -2nd hrly

5)INJ PAN 40gm × IV × OD

6)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD

7)Inj OPTINEURON 1 amp in 100 ml NS/IV×OF

8)IVF 3% Nacl @ 10ml/hr

9)T.ISONIAZID -300 mg - 1 tab/day

    T.RIFAMPSIN -600 mg-2 tab/day

     T.PYRIZINAMIDE-1500 mg -2 tab/day

     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day

                                         100mg-1/day

10)TAB ASPIRIN 150mg × RT×OD

11)TAB ATORVAS 40 mg ×RT ×OD

12)TAB TOLVAPTAN 15 mg × RT × OD

13)TAB THYONORM 25 MCG × RT × OD

14)NEBULISATION  

           ipravent -6th hrly

           Budecort  6th hrly

           mucomist  6th hrly

15) oral suction 2nd hrly

16) position  change 2nd hrly

17)TAB BENADON plus 40mg ×RT ×OD

15/07/21

1)RT feeds 

   100ml milk & 3 to 4 scoops protein powder -4th hrly

2)IVF 3%Nacl @100ml /hr

3)FLUID restriction <5 lit /day

4)Inj CEFTRIAXON 2gm × IV ×BD

5)Inj DEXMETHASONE 8mg×IV × BD

6)INJ PAN 40gm × IV × OD

7)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD

8)Inj OPTINEURON 1 amp in 100 ml NS/IV×OF

9)T.ISONIAZID -300 mg - 1 tab/day

    T.RIFAMPSIN -600 mg-2 tab/day

     T.PYRIZINAMIDE-1500 mg -2 tab/day

     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day

                                         100mg-1/day

10)TAB ASPIRIN 150mg × RT×OD

11)TAB ATORVAS 40 mg ×RT ×OD

12)TAB TOLVAPTAN 15 mg × RT × OD

13)TAB THYONORM 25 MCG × RT × OD

14)NEBULISATION  

           ipravent -6th hrly

           Budecort  6th hrly

           mucomist  6th hrly

15) oral suction 2nd hrly

16) position  change 2nd hrly

17)TAB BENADON plus 40mg ×RT ×OD

16/07/21

1)RT feeds 

   100ml milk & 3 to 4 scoops protein powder -4th hrly

2)IVF 3%Nacl @100ml /hr

3)FLUID restriction <5 lit /day

4)Inj CEFTRIAXON 2gm × IV ×BD

5)Inj DEXMETHASONE 8mg×IV × BD

6)INJ PAN 40gm × IV × OD

7)Inj  THIAMINE 1 amp in 100 ml NS/IV/OD

8)Inj OPTINEURON 1 amp in 100 ml NS/IV×OF

9)T.ISONIAZID -300 mg - 1 tab/day

    T.RIFAMPSIN -600 mg-2 tab/day

     T.PYRIZINAMIDE-1500 mg -2 tab/day

     T.ETHAMBUTOL-900 mg -800mg - 1 tab / day

                                         100mg-1/day

10)TAB ASPIRIN 150mg × RT×OD

11)TAB ATORVAS 40 mg ×RT ×OD

12)TAB TOLVAPTAN 15 mg × RT × OD

13)TAB THYONORM 25 MCG × RT × OD

14)NEBULISATION  

           ipravent -6th hrly

           Budecort  6th hrly

           mucomist  6th hrly

15) oral suction 2nd hrly

16) position  change 2nd hrly

17)TAB BENADON plus 40mg ×RT ×OD,..