A 41 YEAR OLD MALE PT.WITH ALTERED SENSORIUM


Case History and Clinical Findings
PT WAS BROUGHT TO CASUALITY IN ALTERED STATE SINCE YESTERDAY MORNING
PT WAS APPARENTLY ASSYMPTOMATIC UNTILL YESTERDAY MORNING DEVELOPED
ALTERED SENSORIUM , INSIDIOUS ONSET , NOT ORIENTED TO TIME , PLACE , PERSON ,
CONSCIOUS , NON COOPERATIVE
H/O VOMITING 2 EPISODES , GREENISH COLOUR
H/O LOOSE STOOL, SINCE 2 DAYS , 4 EPISODES WATERY CONSISTENCY
H/O LOSS OF APPETITE SINCE 2 DAYS , H/O INADEQUATE SLEEP SINCE SINCE 3 DAYS
NO H/O FEVER , NO H/O DECREASED URINE OUTPUT NO H/O SEIZURE ACTIVITY
K/C/O ALCOHOLIC LIVER DISEASE WITH PORTAL HYPERTENSION SINCE 9 MONTHS ,
STOPPED MEDICATION 10 DAYS BACK
N/K/C/O DM, HTN , TB , EPILEPSY , ASTHMA
GENERAL EXAMINATION
PT CONSCIOUS , INCOHERENT , NON COOPERATIVE
AFEBRILE
PR-94BPM
BP- 130/90 MMHG
CVS- S1S2 +
RS - BAE +
CNS - R L
TONE UL + +
 LL + +
POWER - COULDNT ELICIT
REFLEXES B +2 +2
 T +2 +2
 S +2 +2
 K +3 +3
 A +1 +`1
 P E E
PUPIL - REACTIVE TO LIGHT
COURSE IN HOSPITAL
41 YR OLD MALE WAS BROUGHT TO CASUALITY IN ALTERED STATE , VITALS AT THE TIME
OF ADMISSION PT CONSCIOUS , INCOHERENT , NON COOPERATIVE , PR -94BPM , BP- -
130/70 MMHG , GRBS- 139 MG/DL , SPO2 - 98% ON RA , PT WAS EVALUATED ACCORDINGLY
AND DIAGNOSED AS ALTERED SENSORIUM SECONDARY TO ALCOHOLIC LIVER DISEASE ,
PT WAS TREATED ACCORDINGLY COAGULATION PROFILE WAS DERANGED SO 6. PACKETS
OF FFP WERE TRANSFUSED AND DUE TO FALLING HB 1 PACKET PRBC WAS TRANSFUSED ,
MRI WAS DONE I/V/O INTRACRANIAL HEMORRHAGES NO ABNORMALITY WAS DETECTED
,ON DAY 3 MORNING ENDOTRACHEAL INTUBATION WAS DONE I/V/O FALLING
SATURATIONS AND LOW GCS AND TREATMENT WAS CONTINUED ACCORDINGLY . PT
ATTENDERS WERE EXPLAINED ABOUT THE CONDITION OF THE PT AND NEED FOR
FURTHER TREATMENT AND STAY IN THE HOSPITAL BUT PT ATTENDERS ARE NOT WILLING
TO STAY AND WANT TO LEAVE AGAINST MEDICAL ADVICE .
Investigation
POST LUNCH BLOOD SUGAR 21-03-2024 11:33:AM 134 mg/dl 140-0 mg/dlSERUM CREATININE
21-03-2024 11:33:AM 1.0 mg/dl 1.3-0.9 mg/dlBLOOD UREA 21-03-2024 11:33:AM 70 mg/dl 42-12
mg/dlLIVER FUNCTION TEST (LFT) 21-03-2024 11:33:AMTotal Bilurubin 19.30 mg/dl 1-0
mg/dlDirect Bilurubin 10.4 mg/dl 0.2-0.0 mg/dlSGOT(AST) 411 IU/L 35-0 IU/LSGPT(ALT) 115 IU/L
45-0 IU/LALKALINE PHOSPHATASE 201 IU/L 128-53 IU/LTOTAL PROTEINS 6.1 gm/dl 8.3-6.4
gm/dlALBUMIN 3.0 gm/dl 5.2-3.5 gm/dlA/G RATIO 0.96HBsAg-RAPID 21-03-2024 11:33:AM
NegativeAnti HCV Antibodies - RAPID 21-03-2024 11:33:AM Non ReactiveSERUM ELECTROLYTES
(Na, K, C l) 21-03-2024 11:35:AMSODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 4.0 mmol/L
5.1-3.5 mmol/LCHLORIDE 103 mmol/L 98-107 mmol/LCOMPLETE URINE EXAMINATION (CUE)
21-03-2024 06:54:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY
1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 10-20EPITHELIAL
CELLS 3-4RED BLOOD CELLS loadedCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS
AbsentOTHERS Bacteria seenLIVER FUNCTION TEST (LFT) 22-03-2024 12:07:AMTotal Bilurubin
19.62 mg/dl 1-0 mg/dlDirect Bilurubin 14.22 mg/dl 0.2-0.0 mg/dlSGOT(AST) 325 IU/L 35-0
IU/LSGPT(ALT) 114 IU/L 45-0 IU/LALKALINE PHOSPHATASE 190 IU/L 128-53 IU/LTOTAL
PROTEINS 6.1 gm/dl 8.3-6.4 gm/dlALBUMIN 3.08 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.02STOOL FOR
OCCULT BLOOD 22-03-2024 12:08:AM Positive (+ve)COMPLETE URINE EXAMINATION (CUE)
22-03-2024 04:18:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY
1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL
CELLS fewRED BLOOD CELLS 4-5CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS
AbsentOTHERS Bacteria seenBLOOD UREA 22-03-2024 11:46:PM 113 mg/dl 42-12 mg/dlSERUM
CREATININE 22-03-2024 11:46:PM 1.4 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l)
22-03-2024 11:46:PMSODIUM 139 mmol/L 145-136 mmol/LPOTASSIUM 3.1 mmol/L 5.1-3.5
mmol/LCHLORIDE 98 mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 22-03-2024
11:46:PMTotal Bilurubin 19.81 mg/
dl 1-0 mg/dlDirect Bilurubin 12.85 mg/dl 0.2-0.0 mg/dlSGOT(AST) 299 IU/L 35-0 IU/LSGPT(ALT) 111
IU/L 45-0 IU/LALKALINE PHOSPHATASE 125 IU/L 128-53 IU/LTOTAL PROTEINS 5.5 gm/dl 8.3-6.4
gm/dlALBUMIN 2.88 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.10ABG 23-03-2024 03:24:AMPH 7.382PCO2
16.6PO2 110HCO3 9.6St.HCO3 12.3BEB -15.1BEecf -14.7TCO2 21.9O2 Sat 98.6O2 Count 4.6ABG
23-03-2024 09:20:AMPH 7.39PCO2 19.2PO2 222HCO3 11.4St.HCO3 14.0BEB -12.9BEecf -
12.6TCO2 25.8O2 Sat 99.7O2 Count 5.8
CBP-21/3/24
HB- 6.2
TC- 7200
PCV- 16.9
CBP- 22/3/24
HB- 4.8
TC- 6000
PLT-40000
LDH- 139
RETIC COUNT- 0.9
TROP I - 48.6
USG- ABDOMEN AND PELVIS
PORTAL HYPERTENSION
MILD SPLENOMEGALY
GRADE 2 FATTY LIVER
MILD ASCITES [ FEW MESENTRIC COLLATERALS NOTED IN RT HYPOCHONDRIUM ]
2D ECHO
NO RWMA
EF-68%
GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION
IVC - 1.08 COLLAPSING
SCLEROTIC AV
MRI - BRAIN -
NO ABNORMALITY DETECTED
SERUM LACTATE -23.3

Diagnosis
SEPTIC SHOCK WITH MODS WITH DIC
ALTERED SENSORIUM SECONDARY TO HEPATIC ENCEPHALOPATHY
ALCOHOLIC LIVER DISEASE
SEVERE ANEMIA SECONARY TO ? GI BLEED
S/P ENDOTRACHEAL INTUBATION [DAY-0] ON MECHANICAL VENTILATION


Treatment Given(Enter only Generic Name)
GIVEN RT FEEDS 2ND HRLY
IVF NS @ 50 ML/HR
INJ . NORAD 10.16 MGS /ML @ 12 ML /HR TO MAINTAIN MAP >65
INJ. DOBUTAMINE 15 MG ML @ 3.2 ML /HR TO MAINTAIN MAP
INJ.VASOPRESSIN 2ML /HR
INJ . CEFOTAXIME 2GM IV BD
INJ VIT K 1 AMP IV OD
INJ .MEROPENEM IV 1GM BD
INJ. METROGYL IV TID
INJ.PAN 40 MG IV /OD
INJ .THIAMINE 250 G IV BD
INJ. ATRACURIUM [1MG/ML] @ 5 ML /HR
INJ. TRANEXAMIC ACID 1GM IV BD
INJ . OCTREOTIDE 50 MG IV TIA
T.RIFAGUT 550 MG RT BD
T.UDILIV 300 MG RT BD
T.CARDIVAS 3.125 MG RT OD
SYP .LACTULOSE 15 MG RT BD
SYP. HEPAMERZ 20 ML RT TID
Advice at Discharge
PT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE CONDITION OF PT I.E SEPTIC SHOCK
WITH MODS WITH DIC . ALTERED SENSORIUM SECONDARY TO HEPATIC
ENCEPHALOPATHY , ALCOHOLIC LIVER DISEASE , SEVERE ANEMIA S/P ET INTUBATION [
DAY-0] ON MECHANICAL VENTILATION AND COMPLICATION A/W IT I.E RISK OF DEATH , AND
NEED FOR FURTHER MANAGEMENT AND HOSPITAL STAY . BUT PT ATTENDER ARE NOT
WILLING TO STAY AND WANT TO LEAVE AGAINST MEDICAL ADVISE ,. DOCTOR AND
HOSPITAL ARE NOT RESPONSIBLE FOR ANY UNTOWARD EVENT
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.





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