A 68 year old male with altered sensorium

June 26 2021

Student Name- D.Vineesha Chowdary 

2017 Batch

Roll no.- 24

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. 

A 68 year old Male with altered sensorium

Following is the view of my case:

CHIEF COMPLAINTS:

Patient presented to the casualty in an altered state with GCS E4V1M4

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic until one and a half hour ago when he was going for a nature call and was made to sit on a chair and then he suddenly became altered with a history of fall.

There was history of deviation of mouth to right

No history of involuntary movements, urinary incontinence.

No history of nausea and vomiting.

No h/o head injury,Uprolling of eye balls 

No h/o post ictal confusion 

PAST HISTORY:

K/C/O Asthma since 14 years and on MDI

K/C/O HTN since 7 years and on amlong.

K/C/O of CVA in august 2020 with MCA ischaemic infarct with unresolved AF and with inferior wall MI.

Not a k/c/o Type 2 diabetes, TB.

FAMILY HISTORY:

No history of similar complaints in the family.

No history of DM, TB, Stroke, Asthma, or any other hereditary diseases in the family.

DRUG HISTORY:

T.Amlong 2.5mg PO OD for HTN.

T Amiodarone 150mg PO BD

PERSONAL HISTORY:

Appetite: Normal
Diet: Mixed
Bowel movements: Regular
Bladder movements: Normal 
No known allergies
No addictions

GENERAL EXAMINATION:

The patient is examined in a well lit room with informed consent.
The patient is not conscious, coherent and cooperative and is not oriented to time, place and person.
He is moderately built and nourished.
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent 
Lymphadenopathy: Absent 
Edema: Absent 

VITALS:

On 24/6/21 (At the time of admission):
Temperature- 98.4F
Heart Rate- 132 BPM
Blood Pressure- 180/120 mm of Hg
SPO2- 97% at room air
Respiratory rate- 18/min
GRBS- 151 mg%

SYSTEMIC EXAMINATION:

CVS SYSTEM: S1,S2 heard
No added thrills, no murmurs

RESPIRATORY SYSTEM: 
Position of trachea: Central
Breath sounds: Vesicular breath sounds heard
Adventitious sounds: Not heard

PER ABDOMEN:
Soft, non tender, no organomegaly 

CNS:
Level of consciousness: stuporous
Speech: no response 
Cranial nerves could not be evaluated on presentation
7th nerve examination: Deviation of mouth to right side 

On 25/6/21:
Cranial nerves intact 

Motor system:

Power:
Right sided 4+/5 
left UL - 0/5 
LL - 3/5

Tone:
Right side normal tone both UL and LL
LEFT SIDE tone increased in both UL AND LL 

Reflexes: 

RT SIDED

biceps 3+ , triceps 1+ ,supinator 1+,knee 3+, ankle 2+

LT SIDED 

biceps 3+, triceps 3+ , supinator 3+ , knee 3+, ankle 2+

No cerebellar signs 

INVESTIGATIONS:

1) Serum electrolytes


2) Serum creatinine


3) Blood urea


4) CT scan


5) ECG on 24/6/21


6) ECG on 25/6/21


PROVISIONAL DIAGNOSIS:

Altered sensorium under evaluation 
(Intracranial bleed ruled out)

TREATMENT:

On 24/6/21:

-Tab Nicardia 10mg PO stat

-Tab Ecosporin 150mg PO h/s

-Tab clopitab 75mg PO h/s

-Tab Amlong 2.5mg PO OD

-Tab Atorvas 40 mg PO h/s

-BP charting 4th hourly

On 25/6/21:

-Tab ecosporin 75mg PO

-Inj optineuron 1 ampoule in 100 ml NS OD

-Tab atorvas 40 mg PO

-Tab clopidogrel 75 mg PO

-Tab amlong 2.5mg PO OD

- BP charting 4th hourly

-SYP potchlor 10ml PO BD

-Tab amiodarone 150mg PO BD

Discontinued from the last 4 years

 


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