A case of young male with altered sensorium
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This is a case of 21 year old male , who left his home at the age of 17 and is living separately and working at a hotel near miryalguda.
He was brought to the hospital in unconscious state after he was found lying on the ground with twisted hand and forearm by his roommates
HISTORY OF PRESENTING ILLNESS:
He was apparently asymptomatic 7 days back. Then he developed fever days which was high grade (101 degree Fahrenheit), continuous.
He went to local hospital , took medication but the fever did not subside. Since then he was not going to the hotel where he works and was staying at home.
He had history of vomitings.
4 days back he was found lying on the ground at night 11pm when his roommates returned to their room.
He was found in unconscious state , with twisted arms, forearms, legs suggesting that he had an episode of seizure with involuntary movements of upper and lower limbs.
He also bit his lip
Then they informed his mother and relatives and brought him to the hospital.
He was treated and sent back home.
Later he was brought to the hospital as he was talking inappropriately after be woke up. Patient was in altered sensorium , with slurred speech.
No h/o cough, cold.
No history of neck stiffness, weakness.
PAST HISTORY
No history of Epilepsy ,DM, HTN,TB , ASTHMA
FAMILY HISTORY
No similar history in the family
PERSONAL HISTORY
Appetite- normal
Diet- mixed
Bowel and bladder -Regular
Sleep- Mixed
Habits - alcohol consumption occasionally,
Smoking and chews Tobacco.
EXAMINATION:
General examination:
Pt was not coherent and not cooperative and not oriented to time , place and person.
No pallor , icterus, cyanosis, clubbing, cyanosisand lymphadenopathy.
Non balanchable, non palpable macule over right thigh
VITALS:
Afebrile
Pulse rate : 80bpm
BP : 130/80mmHg
RR : 17 cpm.
CNS EXAMINATION:
He is in altered sensorium and speaking inappropriately.
Cranial nerve examination:
Couldn't examine but CN 3, 4,5 are intact as he is moving his eyes in all directions.
No deviation of mouth.
MOTOR EXAMINATION
BULK : NORMAL
TONE: normal
POWER: >3/5 as he was moving his limbs
SENSORY EXAMINATION
DIAGNOSIS:
Altered sensorium secondary to viral encephalitis?
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