60/M ALTERED SENSORIUM 2°TO ?ACUTE ISCHEMIC STROKE ?MENINGITIS



 This is an 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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan

CHEIF COMPLAINTS AND HOPI.

A 60 year old male who is a resident in telangana ,he does a cotton business. Came to the casualty in altered sensorium on 30/04/2023. 


Patient was apparently asymptomatic 10 years back then he developed fever and went to a ayurvedic doctor and was found to be having retroviral postive.

And started using herbal medicine for that and the symptoms he was experiencing back then was subsided.

1month back patient developed weakness in his left hand with tingling and numbness sensation  which is insidious in onset and gradually progressive in nature with no aggravating and releiving factors  for that he visited the same previous Ayurveda doctor and  started using some herbal medicine  prescribed by him and then, 3to 4 days later, he developed fever (on and off) and no chills and rigors, which is insidious in onset and gradually progressive in nature  along with the fever he also started experiencing leg (both the legs)pain and weakness as well as flank pain for which he went to the same Ayurvedic doctor and he got a scan done    the doctor told him that he had stones in his kidneys and prescribed some herbal medicine with dolo and multivitamin tablets. But after this also the fever did not subsided so they again went to him (Ayurvedic doc) 10 days back and the doctor   adviced some investigations and after that he told that his viral load is high and prescribed herbal medicine which are of high dose and after using this high dose  herbal medicine for 4 to 5 days the patient developed dysphagia and pain in the throat which is insidious in onset and gradually progressive in nature (dysphagia initially to solids and then later to liquids).

He also developed cough  4 days back which is insidious in onset and gradually progressive in nature no history of weight loss,no history of night sweats and after that his responsiveness was decreased and now presented with altered sensorium. 

PSYCHOSOCIAL HISTORY: This patient has a friendly relationship with his family friends as well as neighbors 



PAST HISTORY:


Know case of HIV POSTIVE since 10 years

Known case hypertensive since 3 years. 

Not a known case of DM2,ASTHMA,EPILEPSY,TB,CAD. 


DAILY ROUTINE:

He does cotton business. 

He daily wakes at 5 Am and takes bath and fresh up drinks tea at 7am and then he takes his breakfast  (RICE with vegetable curry )at 8am and goes for his business and comes at 1 pm and takes his lunch which consisting of a vegetable curry and rice and after his lich he chit chat with his neighbors and lie down for some time and after that he watch TV and then eats his dinner at 8pm and goes to sleep at 9pm. 


Family history:No similar complaints in the family .This old man has 4 childern(2 sons and 2daughters) and his wife died 5 years ago due to some health issues.


PERSONAL HISTORY:

DIET:VEGETERIAN 

APPETITE:DECREASED SINCE 2 MONTHS

BOWEL BLADDER :NOT PASSING STOOLS SINCE 4 DAYS.

SLEEP:ADEQUATE 

ADDICTIONS:HE STARTED TAKING BEER 15 DAYS BACK FROM THIS ILLNESS FOR 10 DAYS. 


GENERAL EXAMINATION: 


Patient is drowsy but arousal.

GCS:E2V1M5

BP:130/80mmhg.

PR:110/min

RR:18CPM

SPO2:95%ON 8 LIT OF O2

TEMP: 99°F

PALLOR PRESENT,no icterus,cyanosis,clubbing,lymphadenopathy and edema 


SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD,NO MURMURS. 

RS:BAE+,NVBS.

PA:SOFT AND NONTENDER 

CNS:PUPILS :NORMAL SIZE AND NON REACTIVE. 

TONE:   RT.            LT

        UL HYPER.     HYPER

        LL HYPER.      NORMAL

POWER:

        UL  2/5.          2/5   

        LL  2/5.          2/5

REFLEXES:

        B:   3+         3+

        T:   2+         2+

        S:   2+         2+

        K:   2+        3+

        A:   1+        1+

        P:   EXTENSORS

CLINICAL IMAGES AND INVESTIGATIONS 


                        30/04/23










MRI IAMGES SHOWING INFARCTION:









MRI VIDEO OF THIS PATIENT SHOWING INFARCTS:


                                 01/05/23












         





                              02/05/2023










                               03/05/2023




                               04/05/2023




















    
PROVISIONAL DIAGNOSIS:
RETROVIRAL POSTIVE (10 YEARS)
☆ALTERED SENSORIUM 2°TO? ACUTE ISCHEMIC STROKE(RECURRENT)
?MENINGITIS (?TB)


TREATMENT:

•IVF- NS @50ml/hr
•RYLES FEEDING:100ml water 2nd hourly
200ml milk 4th hourly.
•TAB ECOSPIRIN 150mg/RT/STAT
         •   TAB ATROVASTATIN. 40mg/RT/STAT    


FOLLOW UP  
.................................


01/05/2023

S:
 FEVER SPIKES PRESENT 
STOOLS NOT PASSED .



O:
On examination 
Patient is drowsy but arousal.
GCS:E1V1M3
BP:130/80mmhg.
PR:140/min
RR:18CPM
SPO2:95%ON 8 LIT OF O2
TEMP: 98°F
CVS:S1,S2 HEARD,NO MURMURS. 
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER 
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE:   RT.            LT
        UL HYPER.     HYPER
        LL HYPER.      HYPER
POWER:
        UL  2/5.          0/5   
        LL  2/5.          0/5
REFLEXES:
        B:   2+         2+
        T:   2+         2+
        S:   2+         2+
        K:   2+        3+
        A:   1+        1+
        P:   EXTENSORS


A:
ALTERED SENSORIUM 2°TO ?MENINGITIS,2°TO ?TB,?ACUTE ISCHEMIC STROKE. RETROVIRAL POSTIVE  (10 YEARS)WITH KNOWN HYPERTENSIVE SINCE 3 YEARS .



P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY. 
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
SUCTION 2ND HOURLY.
MONITORING VITALS HOURLY.
PLANNING FOR CBNAAT.
PLANNING FOR LUMBAR PUNCTURE
         


02/05/2023


S:
5 FEVER SPIKES SINCE YESTERDAY 8AM
STOOLS NOT PASSED .


O:
On examination
Patient is drowsy but arousal.
GCS:E1V1M3
BP:110/80mmhg.
PR:140/min
RR:22CPM
SPO2:95%ON 8 LIT OF O2
TEMP: 98°F
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE:   RT.            LT
        UL HYPER.     HYPER
        LL HYPER.      HYPER
POWER:
        UL  2/5.          0/5  
        LL  2/5.          0/5
REFLEXES:
        B:   2+         2+
        T:   2+         2+
        S:   2+         2+
        K:   2+        3+
        A:   1+        1+
        P:   EXTENSORS


A:
ALTERED SENSORIUM 2°TO ?MENINGITIS,2°TO ?TB,?ACUTE ISCHEMIC STROKE. RETROVIRAL POSTIVE  (10 YEARS)WITH KNOWN HYPERTENSIVE SINCE 3 YEARS .


P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY.
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
SUCTION 2ND HOURLY.
MONITORING VITALS HOURLY




WORKSDONE:
LUMBAR PUNCTURE DONE AND CSF SAMPLES WERE SENT FOR CSF ANALYSIS, CSF SUGAR PROTEIN AND
 CBNAAT SAMPLE WAS SENT

BUT ..

The reports of csf analysis and sugar protein  says there is no meningitis...This report says there is no meningitis! 

Can it still be tubercular meningitis? 

Can tubercular meningitis present with hypoglycorrhacia and increased proteins alone inspite of normal cells in CSF?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5893425/
Acellular CSF was also commonly reported among other HIV-infected microbiologically-confirmed TBM!!


03/05/2023


S:
3 FEVER SPIKES SINCE YESTERDAY 8AM( at 4pm,5pm,10pm)
STOOLS NOT PASSED .


O:
On examination
Patient is drowsy but arousal.
GCS:E2V2M3
BP:130/90mmhg.
PR:98/min
RR:26CPM
SPO2:96%ON 8 LIT OF O2
TEMP: 98°F
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE:   RT.            LT
        UL HYPER.     HYPER
        LL HYPER.      HYPER
POWER:
        UL  2/5.          0/5  
        LL  2/5.          0/5
REFLEXES:
        B:   1+         1+
        T:   1+         1+
        S:   1+         1+
        K:   1+        1+
        A:   1+        1+
        P:   EXTENSORS


A:
ALTERED SENSORIUM 2°TO ? TB MENINGITIS,RETROVIRAL POSTIVE  (10 YEARS)WITH KNOWN HYPERTENSIVE SINCE 3 YEARS .



P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY.
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
TAB:ISONIAZID 5mg/kg.PO/OD
Tab:RIFAMPICIN 10mg/kgPO/OD
TAB;PYRAZINAMIDE 25mg/kgPO/OD
TAB:ETHAMBUTOL 15mg/kg PO/OD
TAB:BENADON  40mg po/OD
INJ:DEXA 6mg iv/tid
Inj:PANTOP 40mg iv
SUCTION 2ND HOURLY.
MONITORING VITALS HOURLY.

WORKS:
CBNAAT REPORT  WILL BE UPDATED TOMORROW .MEAN WHILE WE ARE STARTING HIM   ANTI TUBERCULAR THERAPY   EMPIRICALLY.PLANNING TO SEND SAMPLES FOR INFLAMATORY MARKERS. 

QUESTIONS IN THE ROUNDS :



1●WHY IS DEXAMETHASONE  BEING USED  EVEN 
WHEN THE PATIENT IS IMMUNOCOMPRIMISED???




2•WHY ARE WE NOT USING ANTIFUNGALS?


3•WHAT ARE THE MARKERS OF INFLAMMATION???

Inflammation is the body’s innate response to injury
Certain proteins are released into the bloodstream during inflammation,if their concentrations increase or decrease by at least 25%, they can be used as systemic inflammatory markers they are
also known as acute phase reactants, those most commonly used in clinical practice are C-reactive protein (CRP), erythrocyte sedimentation rate (ESR).


4•HOW DOES THE STEROIDS WORKS ON THE CELLS??
https://pubmed.ncbi.nlm.nih.gov/12084906/#:~:text=Steroid%20hormones%20regulate%20cellular%20processes,nucleus%20to%20alter%20gene%20expression


5•WHAT IS THE REASON FOR HIS COMA??
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606267/

Tuberculous meningitis (TBM) is still a crippling disease with a high degree of morbidity and mortality. One of the most severe complications of TBM is stroke resulting from vascular involvement. In HIV-infected individuals with TBM, the immune response to the tuberculous bacilli is altered; therefore, pathological features are very different from those seen in patients with relatively normal cell-mediated immunity (CMI). The brains of such individuals showed minimal inflammatory response with parenchymal infarcts and vasculitis, not only in the basal ganglia but in the cortical parenchyma as well.


https://www.cambridge.org/core/books/uncommon-causes-of-stroke/vasculitis-and-stroke-due-to-tuberculosis/ACB91EF45660A1B7AAD98C17E3DE2701


6•WHAT IS THE REASON FOR HIGH SUGAR AND LOW PROTEIN IN CSF IN MENINGITIS??
During bacterial infection, the protein level in the CSF goes up, due to the increased numbers of replicating bacteria and body cells fighting the infection, with both of them having a high concentration of protein. High levels of lactate in CSF indicate a higher likelihood of bacterial meningitis.

People with bacterial meningitis typically have low levels of CSF glucose because of glycolysis by both white cells and the pathogen and impaired CSF glucose transport. The level of CSF glucose is typically interpreted in relation to that of serum glucose, since glucose passes across the blood–brain barrier.


https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.erbamannheim.com/article/scientific-updates/162%23:~:text%3DDuring%2520bacterial%2520infection%252C%2520the%2520protein,higher%2520likelihood%2520of%2520bacterial%2520meningitis.&ved=2ahUKEwiqnrzzv97-AhX87jgGHViyBXQQFnoECB4QBQ&usg=AOvVaw2qJbhuaqTzjKr6Jflx1zta






On examination in rounds the patient eyes looks like dolls eye that mean the cortex of the patient is not working but the patent  thebrainstill working but the cortex is not working. 







04/05/2023

S:
3 FEVER SPIKES SINCE YESTERDAY 8AM( at 4pm,8pm,9pm)
STOOLS NOT PASSED .


O:
On examination 
Patient is drowsy but arousable.
GCS:E2V2M3
BP:120/80mmhg.
PR:112/min
RR:27CPM
SPO2:96%ON 8 LIT OF O2
TEMP: 98°F
CVS:S1,S2 HEARD,NO MURMURS. 
RS:BAE+,NVBS.
PA:SOFT AND NONTENDER 
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE:   RT.            LT
        UL HYPER.     HYPER
        LL HYPER.      HYPER
POWER:
        UL  3/5.          1/5   
        LL  2/5.          1/5
REFLEXES:
        B:   2+         2+
        T:   2+         2+
        S:   2+         2+
        K:   2+        2+
        A:   1+        1+
        P:   EXTENSORS


A:
ALTERED SENSORIUM 2°TO ? TB MENINGITIS ?FUNGAL MENINGITIS,RETROVIRAL POSTIVE  (10 YEARS)WITH KNOWN CASE OF HYPERTENSIVE SINCE 1YEAR  WITH GRADE 2 BED SORE.




P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY. 
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
TAB:ISONIAZID 275mg/.PO/OD
Tab:RIFAMPICIN 550mg/PO/OD
TAB;PYRAZINAMIDE 1375mg/PO/OD
TAB:ETHAMBUTOL 825mg/kg PO/OD
TAB:BENADON  40mg po/OD
INJ.FLUCONAZOLE 200MG IV/BD.
INJ:DEXA 6mg iv/tid
Inj:PAN 40mg iv /OD.
PLANNING FOR PLEURAL TAPPING UNDER
ULTRASOUND GUIDANCE. 





05/05/2023
ICU BED 4  60/M

DR.RAKESH BISWAS(HOD)
DR.ABHINAYA (SR)
DR.NARSIMHA(PGY2)
DR.HIMAJA(PGY1)
DR.KIRAN(PGY1)

S:
3 FEVER SPIKES SINCE YESTERDAY 8AM( at 2AM,3AM,4AM)
STOOLS NOT PASSED .


O:
On examination
Patient is drowsy but arousal.
GCS:E2V2M3
BP:130/80mmhg.
PR:98/min
RR:28CPM
SPO2:96%ON 8 LIT OF O2
TEMP: 98.7°F
CVS:S1,S2 HEARD,NO MURMURS.
RS:BAE+,DECREASED BREATH SOUNDS ON RIGHT SIDE AND BILATERAL GRUNTING PRESENT.
PA:SOFT AND NONTENDER
CNS:PUPILS :DOLLS EYE+
PUPILS NORMAL SIZE AND NON REACTIVE TO LIGHT.
TONE:   RT.            LT
        UL HYPER.     HYPER
        LL HYPER.      HYPER
POWER:
        UL  2/5.          2/5  
        LL  1/5.          1/5
REFLEXES:
        B:   2+         2+
        T:   2+         2+
        S:   1+         1+
        K:   2+        2+
        A:   1+        1+
        P:   EXTENSORS


A:
ALTERED SENSORIUM 2°TO ? TB MENINGITIS ?FUNGAL MENINGITIS,RETROVIRAL POSTIVE  (10 YEARS)WITH KNOWN CASE OF HYPERTENSIVE SINCE 1YEAR  WITH GRADE 2 BED SORE.




P:
RYLES FEEDING :100ML OF WATER EVERY 2ND HOURLY.
200ML OF MILK EVERY 4TH HOURLY.
IVF:NS@75ml/hr.
Inj.NEOMOL. 1gram IV/SOS. IF TEMP IS greater than 101°F.
TAB:ISONIAZID 275mg/.PO/OD
Tab:RIFAMPICIN 550mg/PO/OD
TAB;PYRAZINAMIDE 1375mg/PO/OD
TAB:ETHAMBUTOL 825mg/kg PO/OD
TAB:BENADON  40mg po/OD
INJ.FLUCONAZOLE 200MG IV/BD.
INJ:DEXA 6mg iv/tid
Inj:PAN 40mg iv /OD.
SYP.LACTULOSE 15 ml PO/HS.
MUCOMIST NEBULISATION 6TH HOURLY.
NEOSPORIN POWDER FOR L/A AT BED SORE.

WORKS DONE:
PLEURAL TAP WAS AND DONE AND SENT FOR INVESTIGATIONS AND HRCT WAS DONE 
AND THE VIDEO OF HRCT:

https://youtu.be/0L8u5ytbVL













SUMMARY::::


Diagnosis : 

Retroviral chronic illness 10 years 

Altered sensorium 3 days
Quadriparesis 
To rule out intracranial space occupying lesion or chronic meningitis 

Respiratory failure type 1 on o2 with right upper lobe cavitory lesions 

History : 

60 year old Man from Telangana presented with altered sensorium one day and quadriparesis for a month (initially hemiparesis). 

On clinical examination he had : 

GCS:E2V1M5 

BP:130/80mmhg. 

PR:110/min 

RR:18CPM 

SPO2:95%ON 8 LIT OF O2 

TEMP: 99°F 

PALLOR PRESENT,no icterus,cyanosis,clubbing,lymphadenopathy and edema 


SYSTEMIC EXAMINATION: 

CVS:S1,S2 HEARD,NO MURMURS.  

RS:BAE+,NVBS. 

PA:SOFT AND NONTENDER  

CNS:PUPILS :NORMAL SIZE AND NON REACTIVE.  

TONE:   RT.            LT 

        UL HYPER.     HYPER 

        LL HYPER.      NORMAL 

POWER: 

        UL  2/5.          2/5    

        LL  2/5.          2/5 

REFLEXES: 

        B:   3+         3+ 

        T:   2+         2+ 

        S:   2+         2+ 

        K:   2+        3+ 

        A:   1+        1+ 

        P:   EXTENSORS 

Course in hospital : 

His respiratory failure was tackled with oxygen therapy and HRCT was planned to investigate further which shows out to be having massive pleural effusion and a diagnostic tap was done and  the right upper lobe cavities visible on chest X-ray as well as cranial MRI was planned to investigate his focal neurodeficits which is showing infarcts in  right frontoparietal and temporal area and altered sensorium with CSF with India InK stain.



Comments

Post a Comment

Popular posts from this blog

57/M with ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA

Image
 Cheif complaints and HOPI  A 56 year old male patient who is a resident of koilagudem (nalgonda district)who is a daily wage labourer by occupation brought to the casualty  in unresponsive state at 1:30 Am .patient was found drowsy from 1 pm on 25/04/2023 And suddenly developed seizure like activity associated with slurring of speech,uprolling of eyeballs,stiffness of all four limbs, Associated with involuntary defecation and micturition and found unresponsive.  No h/o fever ,cough. No h/o neck stiffness and projectile vomitings.  No h/o generalised weakness ,tingling,numbness. No h/o head trauma.  Patient was apparently asymptomatic 6 months back then he developed multipleSwellings Over the Cheek, Forearm, legs with dischargingPus with no pain. for which he went to an RMP and he prescribed Antibiotics but it resolves on for some days and then reappears in 10-15days. He also developed swelling on the nose 6 months back the RMP Removed the pus ,After somedays it healed but the nose be
Read more