21 year old Male with Altered sensorium


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Pt came to casualty in state of altered sensorium with slurring of speech since yesterday


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
PR
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: Altered sensorium under evaluation 2° to dengue encephalitis with pre renal AKI 2° to acute gastroenteritis. 

Investigations
21/09/22
PT 16SEC
INR 1-11 SEC
 Hemogram




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. 







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