A 65YEAR OLD MAN WITH SELF TALKING,VISUAL HALLUCINATIONS,IRRELEVANT TALK ,SLEEP DISTURBANCE,INVOLUNTARY MICTURITION AND A NON HEALING ULCER
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Here is a case i have seen:
A 65 YEAR OLD MALE PATIENT PRESENTED WITH COMPLAINT OF ALTERED BEHAVIOUR AND AN ULCER OVER ANTERIOR ASPECT OF RIGHT FOOT SINCE 6 MONTHS.
PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS BACK, WHEN HE SUSTAINED AN INJURY-A THORN PRICK TO HIS RIGHT LOWER LIMB, WHICH RESULTED IN CELLULITIS FOR WHICH HE WAS TAKEN TO A RMP, WHERE DEBRIDEMENT FOLLOWED BY DRESSING WAS DONE.HE WAS ON REGULAR DRESSINGS.
IT RESULTED IN AN ULCER OVER THE RIGHT LOWER LIMB FOR WHICH DRESSING WAS DONE BY ANOTHER RMP.
HE HAS BEEN ON REGULAR DRESSINGS SINCE 6 MONTHS.
3 MONTHS AGO PATIENT DEVELOPED LEFT LOWER LIMB EDEMA
1 WEEK AGO PATIENT WAS SITTING IN THE FIELD,DURING DAY TIME,(PATIENT DID NOT EAT THAT MORNING) H/O GIDDINESS AND FALL.HE WAS BROUGHT HOME BY VILLAGE PEOPLE. PATIENT DOES NOT REMEMBER THE EVENT OF FALL.NO H/O SEIZURE.HE WAS TAKEN TO A NEARBY HOSPITAL WHERE HIS BP-90/60mm of Hg.
C/O DECREASED APPETITE SINCE 1 WEEK.
AFTER 3DAYS PATIENT STARTED BEHAVING ABNORMALLY,SELF TALKING,VISUAL HALLUCINATIONS,IRRELEVANT TALK,SPITTING FREQUENTLY(EVERYWHERE),INVOLUNTARY MICTURITION AND C/O SLEEP DISTURBANCE.NO ORIENTATION TO TIME,PLACE,PERSON.HE WAS TAKEN TO ANOTHER LOCAL HOSPITAL WHERE HE WAS EXAMINED AND REFERRED.
OUTSIDE REPORTS ON 12/11/2020:
—> HB:6.5,TLC:12000,PLT:2.18
—> SEROLOGY:NEGATIVE
—>RFT:
CREATININE:2.2,
NA+:136MEQ/L
K+:3.0MEQ/L
CL_:100MEQ/L
CA+2=8.0MEQ/L
—>RBS:110MG/DL
H/O CONSUMPTION OF WHISKEY 90ml, TODDY-500ml OCCASIONALLY.
H/O SMOKING SINCE 20YEARS—2CIGARETTES/DAY, STOPPED SMOKING SINCE 3 MONTHS
NOT A K/C/O
DM,HTN,ASTHMA,EPILEPSY,CAD,CVA
PRE HOSPITALISATION EVENTS:
ON PRESENTATION TO US:
PATIENT WAS CONSCIOUS,BUT NOT ORIENTED TO TIME,PLACE BUT ORIENTED TO PERSON,NOT FOLLOWING COMMANDS
HE WAS THIN BUILT
HIS BP WAS 110/70 MM HG
HIS PR WAS 90/MIN
TEMP:AFEBRILE
GRBS-97 MG/DL
SP02:98%ON RA
CVS: S1 S2 +
RS: NVBS+
P/A: SOFT, NON TENDER,BOWEL SOUNDS+
CNS:
INTELLECTUAL FUNCTIONS:
CONSCIOUS+
BEHAVIOUR: IRRITABLE,SELF TALKING,HYPERACTIVE
PATIENT NOT ORIENTED TO PLACE,TIME
BUT ORIENTED TO PERSON
SPEECH:
COMPREHENSION +
REPETITION +
FLUENCY +
MEMORY:
IMMEDIATE RECALL LOST
RECENT MEMORY LOST
REMOTE MEMORY PRESENT
SLEEP: LACK OF SLEEP SINCE 4 DAYS
HALLUCINATIONS: VISUAL+
cranial nerves-1st not elicited
2nd not elicited
rt lf
3rd,4th,6th
pupil size. N N
DLR/CLR. N. N
NO pstosis, nystagmus.
5th sensory not elicited
motor not elicited
reflex :corneal normal,conjuctival normal
7th motor- nasolabial fold normal
no deviation of mouth
sensory not elicited
secretomotor moistness of eye and tongue normal,buccal mucosa normal
8 the nerve:Rinnes and Weber's not elicited
9and 10 th nerve: uvula centrally placed
11 th nerve: trapezieus not elicited
12 th nerve: tongue tone normal, no wasting, no fibrillations,no deviation of tongue
MOTOR SYSTEM
Right. Left
Tone: UL. Normal Normal
LL. normal Normal
Power not elicited
Reflexes:
Superficial reflexes
Right. Left
Corneal. P P
Conjunctival P. P
Abdominal. P. P
Plantar —- mute
Deep tendon reflexes
Right. Left
Biceps. 2+ 2+
Triceps. 2+ 2+
Supinator. - -
Knee 3+ 3+
Ankle. - -
SENSORY SYSTEM
not elicited
Pain present in all four limbs
CEREBELLUM
titubation - absent
Pendular knee jerk - absent
Coordination test not done
MENINGIAL SIGNS
Neck stiffness - absent
Kernigns sign - negative
Brudzinkis sign - negative
LOCAL EXAMINATION: AN ULCER SEEN OVER THE ANTERIOR ASPECT OF RIGHT FOOT
INVESTIGATIONS:
2D ECHO:
ULTRASOUND:
MDCT SCAN BRAIN-PLAIN:
ECG:
SERUM IRON:
SERUM POTASSIUM:
RFT:
ABG:
CUE:
URINE PROTEIN/CREATININE RATIO:
BLOOD GROUPING AND Rh TYPING:
TPR GRAPHIC SHEET:
Reference: http://nithishaavula.blogspot.com/2020/11/a-65-yr-old-male-with-delirium-under.html
TREATMENT:
->IVF-1 NS AND 1 DNS @7.5 ML/HR
->RIGHT LOWER LIMB ELEVATION
->TAB PAN 40 MG PO/OD
->INJ.OPTINEURON 1 AMP IN 500 ML NS/IV @ 7.5 ML/HR
->2PRBC TRANSFUSION DONE ON DAY2 AND DAY4
->TAB.TAXIM-O 200 MG PO/BD
->TAB PANTOP 40 MG PO/OD BEFORE BREAKFAST
->TAB.OLANZAPINE 2.5 MG PO/BD
->TAB OROFER XT PO/BD
->TAB VIT-C OD
->TAB MVT OD
->SYRUP LACTULOSE (SOS)
->ZYTEE GEL FOR L/A OVER ORAL ULCER
->REGULAR DRESSING OF ULCER(WITH MEGAHEAL)
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