59 old male came to casuality with Altered state of consciousness
CASE OF A 59 YEAR OLD MAN .
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THIS IS AN ONGOING CASE, IT WILL BE UPDATED AS AND WHEN WE FIND NEW INFORMATION.
This is the case of a 59 year old male. He is a carpenter by occupation.
He came to casualty with altered state of consciousness.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 months ago , then he had fever - low grade , intermittent , relieves with medication , and not associated with chills and rigor , for 5 days .
He had abdominal distension for 15 days , ascitic tap was done and was told that he had a liver problem, in another hospital.
On 2/7/2021- He had sudden onset of drowsy state and would not respond to their commands.
On 10/7/2021- He became normal and was discharged.
Patient was asymptomatic and was following his normal routine like eating, brushing, bathing for 7 days .
On 17/7/2021- He again became drowsy. He was not able to eat food and brush .
He was admitted in a private hospital for 2 days . As his condition was not improving , his family brought him home and fed him through Ryles tube. As his condition deteriorated day by day ,he was brought to our hospital in a drowsy state.
HISTORY OF PAST ILLNESS
History of altered sensorium one month ago. He was diagnosed with chronic liver disease and portal hypertension one month back.
DRUG HISTORY
No significant drug history.
PERSONAL HISTORY
Bowel and bladder movements - Regular
Appetite - Normal
Chronic alcoholic since 20 years
Non smoker.
Patient is not a known case of hypertension , DM, asthma, epilepsy and tuberculosis.
FAMILY HISTORY
No significant family history .
GENERAL EXAMINATION
Patient is unconscious , non cooperative , disoriented
No pallor, icterus, cyanosis, clubbing , and edema.
No generalised lymphadenopathy.
Brudzinski's sign - Positive
VITALS AT ADMISSION
E2 V2 M5
Temperature -96.5 degrees fahrenheit
Pulse- 93 bpm
BP- 110/80 mmHg
Respiratory rate- 24 cpm
SpO2- 98%
SYSTEMIC EXAMINATION
CVS -
S1 S2 heard
no thrills and murmurs
RESPIRATORY-
BAE+
NVBS
CNS-
Rt Lt
Tone - UL Hypo. Hypo.
LL Hypo. Hypo.
Power- UL -- --
LL -- --
Reflexes- B + --
T -- --
S -- --
K -- --
A -- --
P -- --
PER ABDOMEN
Distended, non tender.
No palpable mass
INVESTIGATIONS
DAY 1
APTT - 32 seconds
BGT - O +ve
PT - 16 seconds
INR - 1.11
HEMOGRAM -
HB- 9.9 g/dl
TLC- 8500 cells per cubic millimeter
Neutrophills - 74 percent
Leukocytes - 10 percent
Monocytes - 10 percent
Eosinophills - 6 percent
PCV - 28.1 percent
MCV - 79.6 percent
MCH- 28 percent
MCHC- 35.2 percent
RDW SD- 48 percent
RDW-CV- 16.7 percent
RBC - 3.53 millions
Platetlets - 1.79 lacks per millimeter cube
Smear - Normocytic , normochromic
LFT -
Total billirubin -1.82 mg/dl
Direct Billirubin -0.48 mg/dl
SGOT -20 IU/L
SGPT - 10 IU/L
Total Protein - 6.1 g/dl
Albumin - 2.2 g/dl
A/G- 0.57
SERUM ELECTROLYTES
Sodium - 128 mEq/L
Potassium - 3.8 mEq/L
Chlorine - 92 mEq/L
RANDOM BLOOD SUGAR - 73 mg /dl
SERUM UREA - 1.2 mg/dl
BLOOD UREA - 61 mg/dl
CSF :1 cell lymphocyte
Pleural fluid Analysis:
820cells
90% lymphocytes
10%Neutrophils
RBCs-present
ECG
ECHO
PROVISIONAL DIAGNOSIS-
Altered sensorium under evaluation.
Hepatic encephalopathy?
DIAGNOSIS
HEPATIC ENCEPHALOPATHY
CHRONIC LIVER DISEASE
GRADE I - BED SORE
TREATMENT
1.DATE- 5.8.2021
RT feeds -
-100 ml free water 1 hourly
-200 ml milk 4th hourly
2. IVF @ 75 ml per hour
-NS
-RL
-DNS
3. Syrup - HEPAMERZ 10ml RT BD
4. Syrup - LACTULOSE 10ml RT TID
5. Tab - RIFAGUT 550 mg RT BD
2. DATE-6.8.2021
1.RT Feeds
-100 ml free water 1 hourly
-200 ml milk 4th hourly
2. IVF Ions @ 50ml per hour
3. Syrup - LACTULOSE 10ml RT TID
4. TAB NORFLOXACIN 400mg
5. Frequent change in position every 2nd hour
6. Syrup- HEPAMERZ
7. OINT. THROMBOPHOR for L/A
3.DATE- 7.8.2021
1.RT Feeds
- 100 ml water- 1 hourly
- 200 ml milk- 4th hourly
2.IVF Ions @ 50 ml/hour
3.Syrup- LACTULOSE 10ml RT TID
4.Tab RIFAGUT 550 mg RT BD
4. DATE- 8.8.2021
1. RT Feeds
-100 ml water - 1 hourly
-200 ml milk- 4th hourly
2. IVF Ions @ 50 ml/hour
3.Syrup LACTULOSE 10 ml RT TID
4.TAB. RIFAGUT 550mg RT BD
5.Soap water enema
5.DATE - 9.8.2021
1.RT Feeds
-100 ml water - 1 hourly
- 200 ml milk - 4th hourly
2.IVF Ions @ 50 ml/hour
3.Syrup LACTULOSE 20 ml RT TID
4.TAB RIFAGUT 550 mg RT BD
5.Soap water enema BD (8 am-x-5 pm)
6. Maintain stools (2-3 )/day
7. GRBS 6th hourly (8 AM--2PM--8PM--2AM)
Date-11.8.2021
SOAP NOTES : SUBJECTIVE:fever spikes absent
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-130/70 mmhg
PR- 86bpm
RR -17 cpm
CVS-S1,S2+
RS- BAE+
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided pleural effusion
PLAN OF CARE-
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
Date 12/08/2021
SOAP NOTES : SUBJECTIVE:fever spikes absent
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-110/80 mmhg
PR- 102bpm
RR -17 cpm
CVS-S1,S2+
RS- BAE+
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided pleural effusion
PLAN OF CARE-
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
Date 13/08/2021
SOAP NOTES : SUBJECTIVE:fever spikes absent
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-110/80 mmhg
PR- 102bpm
RR -17 cpm
CVS-S1,S2+
RS- BAE+
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided pleural effusion
PLAN OF CARE-
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
Date 14/08/2021
SOAP NOTES : SUBJECTIVE:fever spikes absent
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-110/80 mmhg
PR- 102bpm
RR -17 cpm
CVS-S1,S2+
RS- BAE+
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided pleural effusion
PLAN OF CARE-
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
Date 15/08/2021
SOAP NOTES : SUBJECTIVE:fever spikes absent
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-120/80 mmhg
PR- 98bpm
RR -19 cpm
CVS-S1,S2+
RS- BAE+
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided pleural effusion
PLAN OF CARE-
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
SOAP NOTES :
Date-16.8.2021
SUBJECTIVE:fever spikes present
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-100/70 mmhg
PR- 90bpm
RR -17 cpm
CVS-S1,S2+
RS- BAE+
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided exudative pleural effusion
PLAN OF CARE-
Frequent change of position
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
8Inj.THIAMINE 1 amp in 100 ml NS
Date:17/08/2021
SOAP NOTES : SUBJECTIVE:fever spikes absent.
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-120/80 mmhg
PR- 90bpm
RR -20 cpm
CVS-S1,S2+
RS- BAE+
spo2-98%
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided exudative pleural effusion
PLAN OF CARE-
Frequent change of position
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
8Inj.THIAMINE 1 amp in 100 ml NS
Date:17/08/2021
SOAP NOTES : SUBJECTIVE:fever spikes absent.
OBJECTIVE
O/E-E2V3M5
Temperature-98 F
Bp-120/80 mmhg
PR- 90bpm
RR -20 cpm
CVS-S1,S2+
RS- BAE+
spo2-98%
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided exudative pleural effusion
PLAN OF CARE-
Frequent change of position
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
8Inj.THIAMINE 1 amp in 100 ml NS
Date:18/08/2021
SOAP NOTES : SUBJECTIVE:fever spikes absent.
OBJECTIVE
O/E-E4V2M5
Temperature-98 F
Bp-110/60 mmhg
PR- 70bpm
RR -17cpm
CVS-S1,S2+
RS- BAE+
spo2-98%
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided exudative pleural effusion
PLAN OF CARE-
Frequent change of position
INj.CEFTRIAXONE 1gm /iv/BD
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
8Inj.THIAMINE 1 amp in 100 ml NS
9.Soap water anema.
SOAP NOTES : SUBJECTIVE:fever spikes absent.
Date:19/08/2021
OBJECTIVE
O/E-E4V2M5
Temperature-98 F
Bp-90/70 mmhg
PR- 90bpm
RR -17cpm
CVS-S1,S2+
RS- BAE+
spo2-98%
ASSESSMENT-
Hepatic encephalopathy
CLD(compensated)
Bedsores (grade1)
Right sided exudative pleural effusion
PLAN OF CARE-
Frequent change of position
INj.CEFTRIAXONE 1gm /iv/BD
Maintain stools 2-3/day
1.RT feeds
100 ml water 1 hrly
200milk 2hrly
2.IVF 1NS 50ml/hr
3.syp.lactulose20 ml /RT/TID
4.Tab RIFAGUT/RT/OD
5.Soap water enema/BD
6.GRBS 6th hrly
7. Inj OPTINEURON 1amp in 100ml NS IV/TID
8Inj.THIAMINE 1 amp in 100 ml NS
9.Soap water anema.
SUMMARY
59 year old male carpenter who had a routine of work from 9 AM to 6 PM and indulgence in alcohol in the evening .Patient honed the skill of carpentry at the age of 18 Since then he would work to fulfill his necessities . He had an intriguing history of abstinence for 1 year, after which never ending tremors pulled him back to binge on alcohol.
Patient used to work hands on until 2018 , when he met with an RTA which fractured his left leg .After this he limited himself to supervising at his warehouse.
COMMENTS