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?


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