CASE WITH ALTERED SENSORIUM PRESENTED IN SUMMER 2021

 

CASE WITH ALTERED SENSORIUM PRESENTED IN SUMMER 2021

August 19, 2021

 

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A 60 years old female presented in the casualty with complaints of vomiting and altered sensorium.

CHIEF COMPLAINTs

➤10 episodes of vomiting

➤Generalised weakness

➤Drowsiness

➤Body pain

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 days ago after which she developed high grade fever 1 episode and was taken to a local doctor and was treated for the same (medical records not available). Fever subsided yesterday night.

After dinner she had 10 episodes of vomiting and patient had disturbed sleep and generalized weakness and patient was brought to casualty and admitted in the morning.

HISTORY OF PAST ILLNESS 

➤Not a known case of hypertension,diabetes,bronchial asthma,epilepsy and TB

➤No H/O of similar complaints in the past.

DRUG HISTORY

➤No significant drug history.

PERSONAL HISTORY

➤Patient takes mixed diet but has a decreased appetite.

➤Bowel and bladder movement is normal and regular.

➤Self care and hygiene not maintained

➤Alcohol consumption 10 years occasionally once in a month (180ml whiskey)

      But stopped alcohol intake  6 months back.

➤H/O of consumption of tobacco leaves for the past 5 years (2-3 leaves per day)

FAMILY HISTORY 

➤No family history of psychiatric illness.

ALLERGIC HISTORY

➤No significant allergic history

GENERAL EXAMINATION 

➤Pallor : Not seen

➤Icterus :  Not seen

➤Cyanosis :  Not seen

➤Clubbing :  Not seen

➤Lymphadenopathy :  Not seen

➤Edema :  Not seen

➤Malnutrition : Not seen

➤Dehydration: Present

VITALS

➤Temperature : 98.4℉

➤PR : 84 beats per minute

➤BP : 130/70 mmHg

➤RR : 18  cycles per minute

➤SpO2 : 99% in room air

➤Blood Sugar (random) : 186 mg/dl

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent

➤No cardiac murmurs

RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

 ➤Bilateral air entry present

ABDOMINAL EXAMINATION

➤Abdomen is soft

➤Non tender

➤No palpable mass 

➤Bowel sounds are heard

CENTRAL NERVOUS SYSTEM 

Intellectual functions

 -patient is conscious,oriented to time ,place and person

-memory-immediate,recent and remote memory present

-appearence-well kept

-speech-normal 

2)cranial nerves

Olfactory-smell present on both sides

Optic-visual acuity -6/6

    Visual field,colour vision,reflexes -normal 

3,4,6 cranial nerves-ocular movements -present

         Nystagmus,pros is,Diplopoda-absent

       Pupils are normal

Trigeminal -motor and sensory functions normal on both sides

 Facial nerve

-No deviation of mouth 

-frowning present

-absent nasolabial folds on left side

-blowing and whistling absent

Taste sensation on anterior 2/3rd of tongue present

Corneal reflexpresent on both sides

Vestibulocochlear nerve-rinnes Weber,schwabach test Negative on both sides

Vagus and glossopharyngeal -uvula midline

Spinal accessory-shrugging of shoulders present

Hypoglossal-no deviation of tongue

3)Motor system

A)attitude and position-Normal

B)bulk-no wasting

C)tone-Rt Lt

UL N N

LL N N

D)power-

UL Rt Lt

      -5/5 -5/5

LL -5/5 4/5

4)Reflexes

Superficial Rt Lt

  Corneal +2 +2

 Conjunctival +2 +2

Abdominal +2 +2        

Deep Rt Lt

Biceps +2 +3

Triceps +2 +2

Supinator +2 +2

Knee +2 +2

Ankle +2  +2

5)Sensory system  

Superficial -fine touch,temperature,pain -present

Deep-position,vibration,crude touch,stereognosis,2point discrimination- present 

6)Cerebellum 

Speech,nystagmus,ataxia,tremors,released reflexes absent

7)Coordination and gait

Finger nose test ,finger finger test,heel knee test-present

Gait -Normal type

 Romberg test -negative

8)signs of meningeal irritation

Nuchal rigidity,kernigs and brudzinski’s sign - absent

PROVISIONAL DIAGNOSIS :  ALTERED SENSORIUM SECONDARY TO HYPONATREMIA        SECONDARY TO VOMITING

INVESTIGATIONS : 

DAY 1

NORMAL

MILDLY ELEVATED

HYPONATREMIA-130mEq/L

NORMAL

NORMAL

DECREASED LEVEL OF PROTEIN - 5.1g/dl

SERUM BILIRUBIN IS MILDLY ELEVATED

SGPT IS NORMAL

S.CREATININE IS NORMAL

HB is decreased10.6g/dl
TOTAL COUNT IS ELEVATED-12,900cells/cumm

DAY 3

CHEST X-RAY AP VIEW

DAY 1

➤Patient was referred to psychiatry department for cross consultation. 

➤Patient was not cooperative

➤Na- 130 mEq/L

➤Potassium - 3.6 mEq/L

➤Chloride-97mEq/L

➤Hb-10.6g/dl

➤WBC- 12900 cells/cumm

TREATMENT

1) TAB.CLONAZEPAM 0.5mg BD

DAY 2

➤C/O headache

➤Fever spikes absent

➤PR-98 beats/min

➤BP-130/80mm of Hg

➤GRBS-135mg/dl

TREATMENT

1) INJ.3% NaCl continuous infusion @ 15 ml/hour

2) INJ. PAN 40mg IV/OD

3) INJ.ZOFER 4mg IV/TD

4) ORS sachets 2 in 1 litre 

5) BP/PR/TEMP./SpO2 montoring

DAY 3

➤C/O headache

➤Fever spikes absent

➤Patient is conscious and irritable

➤PR-78 bpm

➤BP-160/100 mm of Hg

➤Patient was referred to ophthalmology department for cross consultation

No view of fundus in both eyes due to dense cataract

TREATMENT

1) INJ.3% NaCl continuous infusion @ 15 ml/hour

2) INJ. PAN 40mg IV/OD

3) INJ.ZOFER 4mg IV/TD

4) ORS sachets 2 in 1 litre 

5) BP/PR/TEMP./SpO2 montoring

DAY 4

➤Headache decreases

➤Fever spikes absent

➤Stools passed

➤Patient is conscious ,coherent and cooperative.

➤PR-86 bpm

➤BP-130/80 mm of Hg

➤GRBS-211 mg/dl

TREATMENT

1) INJ.3% NaCl continuous infusion @ 15 ml/hour

2) INJ. PAN 40mg IV/OD

3) IV fluids NS @ 100 ml/hour

4) TAB.PCM 650mg TID

5) INJ.ZOFER 4mg IV/TD

6) ORS sachets 2 in 1 litre 

7) BP/PR/TEMP./SpO2 montoring