A 64 y/o man with altered sensorium who is unable to talk

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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.

3 January 2023 

Case - 

DOA - 28/12/22 

A 64 yrs old male came to the OPD with the chief complaints of - 

Cough since 12 days and inability to talk since 8 days 

Bowel and bladder incontinence since 12 days 

Loss of appetite since 12 days 

Fever 10 days back 

Loose stools 8 days back relieved on taking medication 

Hiccups 8 days back 

History of presenting illness - 

The patient was apparently asymptomatic 12 days back then he developed cough which is insidious in onset and gradually progressive in nature. It is productive type and more on lying down. 

He developed bowel and bladder incontinence along with loss of appetite since 12 days. 

He developed loose stools 8 days back about 5 episodes per day lasting for 1 day which subsided on taking medication. 

He developed hiccups 8 days back 

Since 25/12/22 he is unable to talk 

Past history - 

 He is a k/c/o DM since 7years and is taking medication metformin since 4yrs

No h/o HTN, asthma, epilepsy,CAD 

h/o panic attack one month back due to family issues 

Personal history - 

He used to work as a cattle rearer. Since the time he was diagnosed with diabetes he worked infrequently. From past 3 years he has stopped working as he is unable to walk without using stick. There is also drastic loss of weight since he became diabetic. 

Appetite - Lost 

Diet - Mixed

Bowel and bladder movements - incontinence 

(from past 2 days - constipation) 

Addictions - Occasional alcoholic ( during functions ) tobacco chewing daily since last 30 yrs 

No food / drug allergies 

Family history - 

General physical examination - 

Patient is conscious, incoherent and uncooperative

He is moderately built and nourished 

Pallor : present 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent

Pectus excavatum 

Fixed flexion deformity in both knees 

Vitals - 

Temp: Afebrile 

BP : 100 / 50 mmHg 

PR : 120 bpm 

RR : 16 cpm 

SPO2 : 98 % at RA

GRBS : 193 mg/dl 

Systemic examination - 

CNS - 

GCS : 

E4

V1

M1

Sensory system - 

Pain , touch(fine & crude) , temp, vibration, joint position -  no response 

Motor system - 

                     Right                  Left

Tone -    UL   Hypo             Hypo

               LL   Hypo             Hypo

Power -  UL and LL no movement even with pain 

Reflexes - not elicited 

Brain stem reflexes - 

B/L corneal + , conjunctival + , pupillary + 

Cranial nerves - intact 

Finger nose in coordination - no 

Heel knee in coordination - no 

CVS -  S1,S2 heard, no murmurs ,no thrills 

Respiratory system  - decreased air entry on left side, crackles are heard, position of trachea - central 

Abdomen - soft,  non tender , no organomegaly

Investigations- 

28/12/22 

Hemogram 

RBS 

LFT 

Serum creatinine 

Serum electrolytes 

ECG 

CXR 

USG ABDOMEN 

MRI BRAIN 

29/12/22

Lumbar puncture was performed 

30/12/22 

ECG 

Bacterial culture report 

CSF report 

31/12/22 

Hemogram 

FBS 

Glycated Hb

Serum electrolytes 

Bacterial culture report 

CBNAAT report - TB not detected 

3/1/22

Hemogram 

LFT 

 

Serum creatinine 

Blood urea 

Serum electrolytes 

Provisional diagnosis - 

Altered sensorium secondary to meningoencephalitis (? TB ) 

- Left sided pneumonia ( ?TB ) 

-Pre renal AKI

- Bilateral fixed flexion deformity since 2 yrs 

Treatment plan - 

1) IVF 0.9 %NS IV @ 100 ml / hr 

2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly

3) Inj .Thiamine 200 mg IV/BD in 100 ml NS 

4) Inj . Dexa 6 mg IV / TID 

5) ATT therapy PO/OD FDC:3 tab/ day

6) GRBS monitoring 6 th hrly

7) vitals monitoring 6 th hrly

8) Temp monitoring 4 th hrly

9) Inj H. Actrapid insulin SC TID acc to GRBS 

10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly

11 ) physiotherapy was done