64 year old male with altered sensorium
64 Year Old Male With Altered Sensorium
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A 64 year old male , resident of Choutuppal, presented to the OPD with chief complaints of:
- productive cough and hiccups since 15 days
- loss of appetite and incontinence of both bowel and bladder since 11 days
- unable to talk since 9 days ( the patient is conscious but incoherent )
History of presenting illness : The patient was apparently asymptomatic 15 days back then he developed productive cough that was insidious in onset . He had loss of appetite since 11 days . He also had history of fever and loose stools ( 5 episodes ) for 1 day that releived on taking medications .
He was unable to talk ( incoherent ) since 9 days .
Past history : The patient is a known case of diabetes since 6 years and is on metformin since 4 years .
Not a k/c/o hypertension, epilepsy, thyroid disorders .
Personal history : He used to work as a cattle rearer 3 years back but is not now as he is unable to walk without using a stick .
Diet - mixed
Appetite - decreased
Sleep - adequate
Bowel and bladder movements - regular
Addictions - Occasional alcoholic ( during functions ) and tobacco chewing daily since last 30 yrs .
Family history : The patient's mother had TB 5 years back and was treated . The patient's daughter also had TB 7 years back and was treated .
General Examination : The patient is conscious, incoherent and uncooperative . He is moderately built and nourished .
Pallor - present
Cyanosis, clubbing, generalised lymphadenopathy, pedal edema are absent .
VITALS :
Temperature : 98 F
BP : 110/70 mm Hg
PR : 117 bpm
RR : 17 cpm
GRBS : 188 mg/dl
Systemic Examination :
CNS : The patient is well oriented to person but not to time and place .
GCS : E4V2M1
Motor system examination :
Right Left
Tone : UL hypo hypo
LL hyper hyper
Power : Right Left
UL 0/5 2/5
LL 0/5 0/5
Reflexes : not elicited
CVS :
On palpation ‐
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line.
• JVP was normal
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs
RS : decreased air entry more on the left side,
Position of trachea - central
P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.
Provisional Diagnosis :
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left> right sided pneumonia ( ?TB )
- Prerenal AKI
- B/L fixed flexion deformity since 2 yrs
Investigations :
Fever chart
Hemogram
CXR
Grams Staining and Culture
CBNAAT of CSF fluid tested negative
MRI
Final diagnosis :
- Altered sensorium secondary to meningoencephalitis (? TB )
- Left> right sided pneumonia ( ?TB )
- Prerenal AKI
- B/L fixed flexion deformity since 2 yrs
Treatment :
ATT was started from 31/12/22 .
6 units HAI given in the morning at 8 am .
1) IVF 2 units NS , 1 unit RL IV @ 100 ml / hr
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Tab . Banadon 40mg PO/OD
4) Syp lactulose 15 ml RT / BD
5) Inj .Thiamine 200 mg IV/BD in 100 ml NS
6) Inj . Dexa 4 mg IV / TID
7) ATT therapy PO/OD FDC:3 tab/ day
Isoniazid - 5 mg/kg
Rifampicin - 10 mg/kg
Pyrazinamide - 25 mg/kg
Ethambutol - 15 mg/kg
8) RT Feeds - 100 ml milk + 3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly
9) Passive physiotherapy
My questions regarding this patient :
1) What is the cause of pre renal AKI in this patient ?
2) What is the sensitivity and specificity of diagnosing TB with CBNAAT of CSF fluid in adults ?
In children :
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