Case 32 : 47 year old male with fever ,headache and altered sensorium

 

47 year old male with fever ,headache and altered sensorium

 March 26, 2022

 thanks DR. Divya raju (intern)

CHIEF COMPLAINTS:

Patient came to the hospital with the chief complaints of - fever , headache , altered talking ,walking n confusion.

HOPI:
Patient was apparently asymptomatic 5days back .Then developed-
 High grade fever with chills, intermittent in nature, relieved on medication and was associated with  headache.
Altered sensorium since 2 to 3 hours (not talking and not working properly).
No urine output since morning on 24-3-22
No history of  burning micturition,  vomiting, loose stools,  SOB,  cough ,chest pain, bleeding manifestations.

pERSONAL HISTORY:

Diet- mixed
Appetite- decreased since 3 days
Sleep - indequate
Bowel - regular
Bladder - decreased urine output on 24-3-22

PAST HISTORY:

N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy
ADDICTIONS:
Smokes ,montly once and was a occasional drinker but stopped 1 month back.
No significant drug history

FAMILY HISTORY : not significant

GENERAL EXAMINATION: 

Patient is oriented to time ,place and person
Poorly built and poorly nourished.
Examined under a well lit room.
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- normal

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







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.




LP done on 24-3-22 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?


Comments

Post a Comment

Popular posts from this blog

14/M, massive splenomegaly

Image
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input This Elog also reflects my patient centered online learning portfolio. I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan CONSENT AND DEIDENTIFICATION :  The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever . Case history : 14 yr old male ca
Read more

case 1 : A 41y old man with altered sensorium

Image
  A 41y old man with altered sensorium September 02, 2020 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 is welcome. Here is a case i have seen :  A 41yr old man  who is a farmer came with complaints of pain abdomen and vomitings since one day Patient was apparently alright 2 days back later he had pain abdomen following an acute binge of alcohol(750ml of local liquor) in epigastric region, colicky type,non progressive, non radiating,Which got relieved on taking food He had vomitings-2 episodes, non bilious,non projectile,conte
Read more