A case of young male with altered sensorium

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


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, cyanosis and 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?

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