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

INVESTIGATIONS:

DIAGNOSIS: 

Altered sensorium secondary to viral encephalitis?