A 65YEAR OLD MAN WITH SELF TALKING,VISUAL HALLUCINATIONS,IRRELEVANT TALK ,SLEEP DISTURBANCE,INVOLUNTARY MICTURITION AND A NON HEALING ULCER

November 25,2020

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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:

http://nithishaavula.blogspot.com/2020/11/a-65-yr-old-male-with-delirium-under.html 

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)