47 year old with fever, headache and altered consciousness

 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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome. "I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan


47 year old male , farmer by occupation hailing from nalgonda 

Time line of events - 

■1997  :patient married at 22 years 


■1998: he started smoking and drinking on occasional purposes


■1998-2000: he had two sons and one of the son died due to dog bite following which alcohol consumption was more


■ 2000-2022 : uneventful patient was alright without any complaints


■ 2022, 24th march : 

Patient was apparently asymptomatic 3 days back then developed high grade fever with  chills, intermittent and relieved with meds and associated with severe headache since 3 days ,throbbing in nature

Not associated with burning micturition , vomiting's, loose stools, sob, cough , chest pain, bleeding manifestations

There are complaints of altered sensorium since 3 hours unable to talk and walk properly so was brought to casualty on 24th march

No urine output since morning

PAST HISTORY:

N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy
ADDICTIONS:
Smokes ,monthly once and was a occasional drinker but stopped 1 month back.

GENERAL EXAMINATION: 

Patient is oriented to time ,place and person

No Pallor /Icterus /Cyanosis/clubbing/Edema of feet  /Lymphadenopathy.

VITALS :  
Temp :  101  F 
PR : 90 bpm
BP : 140/80 mmhg 
RR : 18 
SPO2 : 98 % at RA 
GRBS-122 mg/dl

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR SYSTEM :  S1 and S2 heard, no murmurs heard .

RESPIRATORY SYSTEM : Bilateral air entry present ,  clear .

PA : soft and non tender

CNS:

GCS-
E4V3M6, 
pupils- B/L NSRL

HIGHER MENTAL FUNCTIONS:

  • Oriented to time, place, person
  • Memory : immediate, recent, remote intact
  • Speech: normal
  • No delusions or hallucinations

CRANIAL NERVES: 

1- intact

2- not tested

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication + sensations of face)
 
7- normal

8- Normal hearing

9,10- No difficulty in swallowing and speech, gag reflex not tested

11,12- normal.

  MOTOR SYSTEM EXAMINATION :

TONE:  normal

POWER :                    Right       Left
     
    Upper limb          5/5             5/5
    Lower limb          5/5             5/5




Reflexes :                 Right                Left
  1. Biceps:              2+                      2+
  2. Triceps:            2+                      2+
  3. Supinator:      2+                      2+
  4. Knee:                2+                       2+
  5. Ankle:               2+                        2+







Plantars:            extensor          Flexor
Babinski - negative
Meningeal signs-
Neck stiffness -present 
Kernigs sign - positive.

SENSORY EXAMINATION:
Normal

CEREBELLUM EXAMINATION:
  • Able to do finger nose test.
  •  Dysdiadokinesia present
  • No rebound tenderness 
  • Gait: could not be elicited
AUTONOMIC NERVOUS SYSTEM:
  • No abnormal sweating
  • No resting tachycardia



MRI Impression (24-3-22)

- Few lacunar infarcts in medulla on left side.No f/o raised ICT on MRI 






Chest x-ray (24-3-22)



Ultrasound report (24-3-22)




ECG




Opthal- fundoscopy i/v/o any raised ICT for  LP




Investigations:


Blood culture report (26-3-22)


Urine culture report(26-3-22)





Fever charting





TREATMENT: 

On 24-3-22

IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 8 MG IV STAT
TAB DOLO 650 MG RT/SOS
BP,PR monitoring 4 th hourly

On 25-3-22

IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS if temp >101°F
INJ.Thiamine 1 amp in 100ml NV/IV/OD
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 4 MG IV STAT
INJ DOXY 100 mg IV BD
Strict  I/O charting
W/f seizure activity
INJ. Vancomycin 2mg IV stat
INJ.Optineuron 1amp + 500ml NS over 1hr
BP,PR monitoring 4 th hourly


On 26-3-22

IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ.Thiamine 1 amp in 100ml NV/IV/OD
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 4 MG IV STAT
INJ DOXY 100 mg IV BD
TAB DOLO 650 pO TID
Strict  I/O charting
W/f seizure activity
INJ. Vancomycin 1mg IV BD
INJ.Optineuron 1amp + 500ml NS over 1hr
BP,PR monitoring 4 th hourly

On 27-3-22

IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ.Thiamine 200mg IV BD
INJ. MONOCEF 1 GM IV BD
INJ. DEXA 4 MG IV BD
INJ DOXY 100 mg PO BD
TAB DOLO 650 pO TID
Strict  I/O charting
W/f seizure activity
INJ. Vancomycin 1mg IV BD
INJ.Optineuron 1amp + 100ml NS over 1hr
BP,PR monitoring 4 th hourly.

On 28-03-2022

IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ.Thiamine 200mg IV BD
INJ. MONOCEF 1 GM IV BD
INJ. DEXA 4 MG IV BD
INJ DOXY 100 mg PO BD
TAB DOLO 650 pO TID
Strict  I/O charting
W/f seizure activity
INJ. Vancomycin 1mg IV BD
INJ.Optineuron 1amp + 100ml NS over 1hr
BP,PR monitoring 4 th hourly.


Lumbar puncture:  done on 25-3-22 at 2 am - showing around 450 cells? Lymphocyte predominant,
Glucose - 32
Protein - 195
Chloride - 120
 GRBS at time of LP - 112mg/dl

Provisional diagnosis- meningitis 

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