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 , with complaints of fever and headache since 3 days and altered sensorium since 3hours  (24th March)

Time line of events - 

N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy

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+

Video Reference: https://divyaraju26.blogspot.com/2022/03/47-year-old-male-with-fever-headache.html

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

Investigations:

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

MRI Impression

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

Chest x-ray 

Ultrasound report 

No sonological abnormality

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.

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.

On 29-03-2022

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.

Provisional diagnosis- meningitis