57 YEAR OLD MALE WITH CHEIF COMPLAINTS OF FEVER, ALTERED SENSORIUM FROM 1 MONTH

 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 57-year-old male resident of Nalgonda security guard by occupation came with the chief complaints of fever since 1-month, generalised weakness since 1 month and altered sensorium 1 month back for 3 days.

HISTORY OF PRESENTING ILLNESS

Patient developed generalised weakness 1 month with blurring of vision which was insidious on onset not progressive, after 2 days he developed fever which was 103 degrees. Fever was insidious in onset, gradually progressive no aggravating and relieving factors known. After two days of onset of fever he suddenly fell in bathroom due to weakness in legs and hurt his head. Upon approaching the patient family observed slurring of speech. He was then taken to government hospital. He approached the car by himself walking with the help of a stick during the travel to hospital he showed symptoms of altered sensorium where he was responding lately. He was kept in ward and treated only with glucose without any medications. He was then taken to a private hospital where his condition worsened and was unable to remember things which happened 10 mins back and could not recognise anyone except his elder daughter. As he was being taken to MRI, he lost consciousness and completely stopped responding. MRI was taken and high dose antibiotics were given where he regained consciousness and could slowly start recognizing his family members. There he was treated strong enough to transport to our hospital. They did an elective tracheostomy and sent him to our hospital. Upon reaching our hospital CSF analysis were done and treatment was started. Fever subsided completely and he was afebrile for a week. After a week into the treatment, he developed shortness of breath, he started developing pneumothorax to which a inter coastal drainage tube was placed. He was on ventilator for some time after this episode. Later 3 days after pneumothorax the patient developed a bed sore and along with-it developed fever. This time it was continuous gradually progressive relieved on medication. Upon history he said that he had a surgery for cervical spondylosis 4 years back. After the surgery he could not bear the fan and could not sleep directly in its wind. It gradually increased and reached to a level of high discomfort 2 months back. He had history of constipation for 10 days 1 month back where enema was done in the private hospital. He never had free bowel movements and had problem since a long time. Upon history taking there was another finding of sound during respiration from 1month before the onset of generalised weakness it increased gradually and was not seen after tracheostomy. There was history of rolling over of eyes during MRI scan in the private hospital. There is no history of involuntary movements, seizures, involuntary micturition, or defaecation. No history of vomiting.

PAST HISTORY

He was diagnosed with cervical spondylosis and lumbar spondylosis 4 years back upon which he was advised for surgery for cervical spondylosis and normal conservational treatment for lumbar spondylosis. After the surgery he was bed ridden for 6 months. Before diagnosis he had muscle tightness in his peripheral muscles which was relieved after surgery. Later the lumbar spondylosis worsened and upon approaching doctors the said that he would be unable to walk after operation so they didn’t go through with the operation. He is a known hypertensive from 7 years and was not on medication regularly thinking about his financial status. Not a known case of diabetes, Tuberculosis, epilepsy, coronary artery disease.

PERSONAL HISTORY

Diet: Mixed
Apetite: Normal
Bowel movements: Decreased
Bladder movements: Normal
Drinks toddy occasionally
No history of tobacco, smoking

FAMILY HISTORY

No similar complaints in the family

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative. Moderately built and nourished
No pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, pedal edema.

VITALS

Temperature: 103 C
Blood pressure:130/90 mmHg
Pulse rate: 96 bpm
Respiratory rate: 24 cpm

TRACHEOSTOMY

THORACOCENTESIS



Scar from cervical spine surgery




SYSTEMIC EXAMINATION

CARDIOVASCULAR EXAMINATION

S1, S2 heard. No murmurs

RESPIRATORY EXAMINATION

Chest symmetrical, normal vesicular breath sounds heard, no additional breath sounds

ABDOMEN

Abdomen is soft, non-tender, no organomegaly

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher mental functions: Intact

CRANIAL NERVES
Olfactory: Normal
Optic: Normal
Oculomotor, trochlear and abducens: Normal
Trigeminal: Normal
Facial: Normal
Vestibulocochlear: Normal
Glossopharyngeal, vagus: Normal
Spinal accessory: Normal
Hypoglossal: Normal

MOTOR FUNCTIONS

Bulk: Normal in all four limbs
Tone: Normal in all four limbs
Power: Upper limb left 4/5, Upper limb right 4/5
              Lower limb left 4/5, Lower limb right 4/5
              Neck muscles good
              Trunk muscles good
              Plantar reflex present on both sides
Reflexes: Superficial reflexes: Corneal, conjunctival, pharyngeal: Present
                 Deep tendon reflexes: Biceps reflex 2+ on both sides
                                                      Triceps reflex 2+ on both sides
                                                      Supinator jerk 2+ on both sides
                                                      Knee jerk 2+ on both sides
                                                      Ankle jerk 2+ on both sides

Coordination tested along with cerebellum normal
No involuntary movements

SENSORY SYSTEM

Spinothalamic: Crude touch, pain, temperature normal on both sides on all limbs
Posterior column: Fine touch, Vibration, Position sense present on all limbs
Cortical: Two-point discrimination, Tactile localisation, Graphesthesia, Stereognosis normal

CEREBELLAR SIGNS

No nystagmus, coordination intact in upper and lower limbs, hypotonia absent

NO SIGNS OF MENINGEAL IRRITATION (Neck stiffness, kernig’s sign, Brudzinski sign)

No thickened nerves in periphery, trophic ulcers, wrist drop or foot drop

DIAGNOSIS

CVA with acute ischemic stroke (infarct in cortical and subcortical regions of occipital lobe) with hyponatremia (resolved) with AKI on CKD (resolved) with hypertension for past 7 years

INVESTIGATIONS

ON 27/05/23













ON 02/06/23



                                                        

 

 

 

 

 

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