A 65 year old male, chronic alcoholic with altered sensorium

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A 65 YEAR OLD MALE WITH ALTERED SENSORIUM UNDER EVALUATION

Chief complaints:

• Fever since 2-3 days, associated with generalized weakness. 

•  Irrelevant talk and drowsiness since 1 day

History of present illness:

. Patient was apparently asymptomatic, 3 days back. 

• From the past 3 days, he developed fever, associated with generalized weakness

• Also has history of irrelevant talk and drowsiness since 1 day

• Has history of binge drinking  , since 4-5 days, without eating. 

• Has no history of headache, cough, vomiting 

History of past illness:

• Has history of rt. femur fracture due to fall from a bike 6 months back. 

• Similar complaints in the past due to excessive drinking

Treatment history:

•  Has undergone a surgery for right femur

• Has no treatment history of DM, HTN, CAD, asthma, stroke, blood transfusion, TB, hormones, antibiotics, chemoradiation. 

Personal history:

• Pt is married and is farmer by occupation. 

• His appetite is normal, and follows a mixed diet. 

• Has regular bowel habits and normal micturition

• Has no known allergies

• He's an alcoholic, consumes alcohol regularly, since 40 years

• Has a habit of smoking chutta since 40 yrs, 4-5 per day

Family history:

• Has no family history of DM, HTN, TB, asthma, cancers, stroke, heart diseases

Physical Examination:

• Has no pallor, no cyanosis, no lymphadenopathy, no clubbing , no oedema of feet, no malnutrition and no dehydration

• Icterus - present

Systemic Examination:

A. Cardiovascular system

• No thrills and no cardiac murmurs

B. Respiratory system

• No dyspnoea and wheeze

. Normal vesicular breath sounds heard

. Position of trachea - central

C. Abdomen 

• Shape of abdomen - obese

• Tenderness - present in right hypochondriac and epigastric regions

• Has no palpable mass, bruits, free fluids

• Liver and spleen are not palpable

• Bowel sounds - heard

• Hernial orifices - normal

D. Central Nervous system 

•  NAD

Investigations :

On 10.8.21

1. ECG

2. Ultrasound report 

On 11.8.21

LDH - 1,175.8 IU/L

HCV - positive

Provisional diagnosis:

ALTERED SENSORIUM UNDER EVALUATION

SECONDARY TO ALCOHOLIC INTOXICATION, UTI, PNEUMONIA

? ACUTE VIRAL HEPATITIS( HCV)

Treatment :

On 10.8.21

• IVF 10 NS with 2 ampules thiamine/IV

• INJ. PAN 40 mg/IV / BD

• INJ. Optineuron 1 ampule in 10 NS/IV/OD

• Head end elevation

• Inj. Neomol 1gm/IV infusion

• T. PCM 650 mg

• Monitor BP, PR ,  RR

• Strict I/O charting

• Tepid sponging and temperature charting 4th hourly

• O2 inhalation @ 15L/min to maintain SPO2 >95%

• IVF - 0.9% NS - Continuous infusion @ 75ml/hr

• Nebulization with BUDECORT /6th hourly

• Syp. LACTULOSE 10ml/BD

> On 11.8.2021 , at 1:30 pm, patient started having tachypnoea with respiratory rate of 44 cpm, and hypoxia ( type 1 respiratory failure) 

> Patient suddenly developed weakness of right upper limb and right lower limb with blood pressure of 110/80 mmHg and worsening GCS :  E1 V1 M1

> On suspicion of CVA : IC bleed / acute infarct - CT brain was done which showed no significant abnormalities

> Patient was intubated in v/o poor GCS and falling saturations. 

 But pt had bradycardia and was in asystole for which CPR was initiated according to the aha guidelines, 2015  yet pt couldn't be revived. ECG showed no electrical activity and pt was declared dead at 7:36 pm on 11/8/2021

DEATH SUMMARY 

Date of death :11/08/2021 

Ward:ICU

Unit:2

Name of Treating Faculty

DR SAI RAGHU (INTERN)

DR LAKSHMI MANASA (INTERN)

DR ROOPA (INTERN)

DR JANCY (INTERN)

DR RAVALI (INTERN)

DR VAMSI KRISHNA PGY1

DR RASHMITHA PGY2

DR NIKITHA PGY2 

DR HAREEN (SR)

DR ARJUN KUMAR (AP)

DR RAKESH BISWAS (HOD)

Diagnosis

TYPE 1 RESPIRATORY FAILURE SECONDARY TO PENUMONIA ? ASPIRATION/INFECTIVE ? ACUTE INFARCT IN BRAIN STEM

ALCOHOLIC DELIRIUM

ACUTE VIRAL HEPATITIS( HCV+ve)

? ALCOHOLIC HEPATITIS

Case History and Clinical Findings

A 65 YEAR OLD MALE CHRONIC ALCOHOLIC WITH C/O FEVER SINCE 2-3 DAYS ASSOCIATED WITH GENERALISED WEAKNESS ,IRRELEVANT TALK AND DROWSINESS SINCE 1 DAY.

H/O BINGE DRINKING SINCE 4-5 DAYS WITHOUT EATING 

IRRELEVANT TALK AND DROWSINESS SINCE 1 DAY

NO H/O HEADACHE/VOMITING/SEIZURES

NO OTHER COMPLAINTS

NOT A K/C/O OF DIABETES,HYPERTENSION,TB,ASTHMA

GENERAL EXAMINATION:PATIENT IS CONSCIOUS, NON COOPERATIVE AND NOT WELL ORIENTED TO TIME AND PLACE 

TEMP: 100F

PULSE RATE; 141BPM

BP :110/70mmhg

RR-  20cpm

ICTERUS +

NOPALLOR,CYANOSIS,CLUBBING,OEDEMA,GENERALISED LYMPHADENOPATHY

SYSTEMIC EXAMINATION : 

CVS: S1S2 HEARD

NO THRILLS AND MURMURS

RESPIRATORY SYSTEM: NVBS +BAE +

PER ABDOMEN :ABDOMEN IS SOFT ,TENDERNESS PRESENT IN RIGHT HYPOCHONDRIUM AND EPIGASTRIC REGION 

THERE IS NO PALPABLE MASS

BOWEL  SOUNDS +

CENTRAL NERVOUS SYSTEM: GCS: E3 V2 M4.

ALL SUPERFICIAL AND DEEP REFLEXES  ARE NORMAL

Treatment Given(Enter only Generic Name)

1.IV FLUIDS

2.INJ.CEFTRIAXONE 1gm IV/BD

3.INJ.PAN 40MG

4.INJ.OPTINEURON 1amp IN 100ml IV/OD

5.IV FLUIDS 0.9%NS CONTINUOUS AT 75ML/HR 6.TAB.PCM 650 MG TID

7.SYP.LACTULOSE 15ML BD

8.INJ. NEOMOL 1GM IV SOS

9.BP/PR/TEMP/SPO2 MONITORING

10.NEB WITH IPRAVENT AND BUDECORT - 6TH HOURLY 

11.HEAD END ELEVATION WITH O2 INHALATION AT 3-4 Lit

12.TAB.OLANZEPINE 5MG/H/S

13.T.DOXYCYCLINE 100MG/OD

PATIENT SUDDENLY BECAME UNRESPONSIVE WITH GCS OF E1V1M1( 3/15) HYPOXIC AND TACHYPNEA.

IN V/O POOR GCS AND FALLING SATURTAIONS PATIENT WAS INTUBATED WITH ET 7.0 AND IMMEDIATELY AFTER INTUBATION PATIENT HAD CARDIAC ARREST

BP,PR-NR

CPR WAS INTIATED ACC. TO 2015 AHA GUIDELINES

7:05 PM : BP, PR-NR CPR INITIATED INJ. ADRENALINE 1CC IV/STAT

7:10 PM : BP , PR - NR CPR CONTINUED INJ.ADRENALINE 1CC IV/STAT

7:15 PM : BP , PR - NR CPR CONTINUED INJ.ADRENALINE 1CC IV/STAT

7:20 PM : BP , PR - NR CPR CONTINUED INJ.ADRENALINE 1CC IV/STAT

7:25 PM : BP , PR - NR CPR CONTINUED INJ.ADRENALINE 1CC IV/STAT

7:30 PM : BP , PR - NR CPR CONTINUED INJ.ADRENALINE 1CC IV/STAT

7:35 PM : BP , PR - NR CPR CONTINUED INJ.ADRENALINE 1CC IV/STAT

DESPITE OF THE ABOVE RESUSCITATION MEASURES PATIENT COULD'NT BE REVIVED AND DECLARED DEAD AT 7:36PM ON 11/8/21.

DEATH SUMMARY

A 65 YR OLD MALE PRESENTED TO CASUALTY WITH ALTERED STATE AND GCS E3V2M4 AND PUPILS NSRL

PATIENT ATTENDERS GAVE A HISTORY OF INCREASED INTAKE OF ALCOHOL 6 DAYS WITHOUT FOOD INTAKE

INTEGRATING THE HISTORY AND CLINICAL PRESENTATION A WORKING DIAGNOSIS OF DELIRIUM SECONDARY TO ALCOHOL INTOXICATION WERNICKES ENCEPHALOPATHY ( METABOLIC ETIOLOGY) WAS MADE AND PATIENT WAS GIVEN SUPPORTIVE TREATMENT VITALS BEING STABLE

ON 11/08/2021 AT 1:30 PM ,PATIENT STARTED HAVING TACHYPNEA WITH RESPIRATORY RATE OF 44cpm,(TYPE 1 RESPIRATORY FAILURE )

PATIENT SUDDENLY DEVELOPED WEAKNESS OF RIGHT UPPER LIMB AND LOWER LIMB WITH BLOOD PRESSURE OF 110/80MMHG AND WORSENING GCS E1V1M1.

ON SUSPICION OF CVA IC BLEED/ ACUTE INFARCT

,CT WAS DONE WHICH TURNED OUT TO BE NORMAL AND IN VIEW OF FALLING SATURATIONS, POOR GCS ,PATIENT WAS INTUBATED BUT HE HAD BRADYCARDIA AND WAS ASYSTOLIC FOR WHICH CPR WAS INITIATED ACCORDING TO AHA GUIDELINES 2015,YET PATIENT COULD'NT BE REVIVED AND ECG SHOWED NO

ELECTRICAL ACTIVITY AND PATIENT WAS DECLARED DEAD AT 7:36PM ON 11/8/2021 

IMMEDIATE CAUSE OF DEATH : 

TYPE 1 RESPIRATORY FAILURE

SECONDARY TO PNEUMONIA

ANTECEDENT CAUSE OF DEATH :

 ? ACUTE INFARCT INVOLVING BRAIN STEM

ALCOHOLIC DELIRIUM

ACUTE VIRAL HEPATITIS HEP C 

ALCOHOLIC HEPATITIS

Faculty Signature

SIGNATURE OF PATIENT /ATTENDER : 

SIGNATURE OF PG/INTERNEE:

SIGNATURE OF ADMINISTRATOR : 

SIGNATURE OF FACULTY: