01 HARIKRISHNA

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              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,..

                           




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