36yr old with altered sensorium and quadriparesis

E-LOGS GENERAL MEDICINE

 

Roll no 04 

Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

A 36yr old male patient came to OPD with altered sensorium and quadriparesis. 

CHIEF COMPLAINTS :

Fever since 15 days

Weakness of bilateral upper and lower limbs since 3 days .

HISTORY OF PRESENT ILLNESS:

He had delayed milestones in his childhood (I .e, walked at the age of 6yrs )and ( slurring of speech since he was 6yrs ).

Patient was apparently asymptomatic 15 days ago when he started to develop fever which was intermittent and relieved on use of medication.

Then he presented to casualty with altered sensorium and quadriparesis.

PAST HISTORY:

K/c/o epilepsy since he was 6 months of age .

Not a k/c/o diabetes

                    Hypertension

                    TB , CAD

                     Asthma 

PERSONAL HISTORY:

Diet - mixed

Appetite - normal

Bowel and bladder movements - normal

Addictions - no history of alcohol consumption and usage of tobacco .

Sleep - normal 

FAMILY HISTORY:

No significant family history .

GENERAL EXAMINATION:

Conscious , intellectual disability 

Pallor - not seen

Icterus - not seen

Cyanosis - not seen

Clubbing- not seen

Lymphadenopathy - not seen

Oedema - not seen 

VITALS :

Temperature - 101°F

Pulse rate - 100/min

Respiratory rate - 20/min

BP - 150/80 mmHg 

SpO2 - 98%

GRBS - 156mg%

SYSTEMIC EXAMINATION:

CVS : 

S1 and S2 heard 

No thrills and murmurs

RESPIRATORY SYSTEM: 

BAE +

ABDOMEN:

Soft and non tender 

CNS : 

Glassgow coma scale : 

E4 V2 M2 

Quadriparesis 

Intellectual disability

Altered sensorium

Slurred speech (since 6yrs of age )

Fine motor skills attained at age of 2yrs

Vision and hearing are normal since birth.

PROVISIONAL DIAGNOSIS : 

Fever with altered sensorium

Sepsis

Quadriparesis

Motor axonal neuropathy

Myositis 

AKI (pre renal )

Leptospirosis 

Meningitis 

INVESTIGATIONS :

TREATMENT:

1) RT FEED 100ml milk with protein powder 

                     100ml water 

2)INJ MONOCEF 2mg IV/BD 

3)INJ PAN 40mg IV /OD 

4)IVF ONS

5) GRBS CHARTING 

6) TEMPERATURE CHARTING 

7) Monitor vitals 

8) strict I/O charting 

9) INJ NEOMOL 

10) TAB PCM 

11) TEPID SPONGING