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 

 

Curious case of 55 year old male with seizures

 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

     

55 year old male hailing from nalgonda , farmer by occupation presented to our casuality in post cardiac arrest- intubated state on 5th march at 4:27pm

HOPI

▪︎No loss of consciousness,seizures,giddiness following trauma

●Not a known case of HTN,DM,ASTHMA,STROKE

PERSONAL HISTORY

●Non vegetarian consumes pork meat with normal appetite,regular B&B movements

● No known allergies ,smoker and alcholic for the past 20 years and no history of weight loss

Family history

● h/o seizures in both of his grand children 

examination

• Vitals at the time of admission:

Temp: 99.8•F

PR: 114bpm

RR:18cpm

BP: 110/60mm hg

Spo2: 96%on O2 

GRBS: 196mg/dl 

CVS: S1S2+

RS: BEA+, NVBS+

P/ A: SOFT, NON TENDER

CNS: 

Pupils - b/l nsrl

Reflexes   B   T   S. A. K.  plantar- 

            L - 2+ 2+ 2+ -  3+  extended

           R - 2+ 2+ 2+ -  +3  extended

■ Provisional diagnosis - seizures under evaluation(? Alcohol withdrawal seizures) with post ictal confusion 

     ? Hypoxic encephalopathy 

     Post CPR status day 5

Rx 

1. Head end elevate 30•

2. Inj . MEROPENEM 1gm/IV/BD

3. Inj.LEVIPIL 500mg / IV/ BD

4.Inj. Mannitol 100ml/IV/BD

5.Inj. MIDAZO LAM 10mg - 50 mgNS (@ 3ml / hr)

6.Inj. Pantop 40mg/IV/OD

7. Inj.Neomol 100 ml/if temp >101.5•

8.RT feeds —-100 ml with nills

(2 hourly )        100ml with free water

9. Vitals monitoring hrly

10.Fever chart Hourly

11.Inj.thiamine 2AMP in 100 ml ns/iv/bd 

● Ecg taken on day 1

■ Investigations done - 

Updates 

■ Day 2 Soap notes - O/E  patient is on mechanical ventilator 

Gcs- E1 V M2

Febrile -100.1•F

BP-140/80mmHg

PR-112bpm regular , normal volume

RR-18cpm

Cvs: S1S2 heard no murmurs

RS:  NVBS+

P/ A: SOFT, NON TENDER

CNS: pupils -b/l nsrl (at 7:00AM)

            

Reflexes   B   T   S. A. K.  plantar- 

            L - 2+ 2+ 2+ -  3+  extended

           R - 2+ 2+ 2+ -  +3  extended

 (at 10:35AM) Sluggish pupil reaction

                         Dolls eye absent

Rx 

1. Head end elevate 30•

2. Inj . MEROPENEM 1gm/IV/BD

3. Inj.LEVIPIL 500mg / IV/ BD

4.Inj. Mannitol 100ml/IV/BD

5.Inj. Pantop 40mg/IV/OD

6. Inj.Neomol 100 ml/if temp >101.5•

7.RT feeds —-100 ml with nills

(2 hourly )        100ml with free water

8. Vitals monitoring hrly

9.Fever chart Hourly

10.inj Monocef 1gm/iv/bd

11.Inj.thiamine 2AMP in 100 ml ns/iv/bd 

Investigations-

● Diagnosis - seizures 2• to ? tuberculoma/NCC

                                              ? Alcohol

         With hypoxic encephalopathy, post cpr status day 6,  mechanical ventilation day 5

■ Day 3 soap notes 

O/E  patient is on mechanical ventilator 

Gcs- E1 V M2

Fever spikes+

BP-130/90mmHg

PR-120bpm regular , normal volume

RR-18cpm

Cvs: S1S2 heard,muffled heart sounds

RS:  NVBS+

P/ A: SOFT, NON TENDER

CNS: pupils -b/l nsrl

            

Reflexes   B   T   S.   A.  K.    plantar- 

            L - 2+ 2+ 2+    -   -      extended

           R - 2+ 2+ 2+    -    -      extended

Spo2-92%

Rx 

1. Head end elevate 30•

2. Inj .MIDAZOLAM 10mg in 50ml ns @3ml/hr

3. Inj.LEVIPIL 500mg / IV/ BD

4.Inj. Mannitol 100ml/IV/BD

5.Inj. Pantop 40mg/IV/OD

6. Inj.Neomol 100 ml/if temp >101.5•

7.RT feeds —-100 ml with nills

(2 hourly )        100ml with free water

8. Vitals monitoring hrly

9.Fever chart Hourly

10.inj Monocef 1gm/iv/bd

11.Inj.thiamine 2AMP in 100 ml ns/iv/bd 

Advised 2D echo

Investigations-   

● Diagnosis - seizures 2• to ? tuberculoma/NCC

                                              ? Alcohol

         With hypoxic encephalopathy, post cpr status day 7,  mechanical ventilation day 6

Fever chart

S:- no fever spikes

O- O/E : patient is on mechanical ventilator

          PEEP- 5

          FiO2 - 40% 

          VT - 400ml

          Timp : 2.1

          VITALS:

temp- afebrile

BP: 110/90mm hg 

PR: 115 bpm. 

RR: 16 cpm 

spo2: 99% with Fio2 40%

GRBS: 168 mg/dl

CVS - S1, S2 heard ,no murmurs

RS. :- NVBS Present, no crepts

P/A: soft, non tender 

CNS: Pupils :B/L NSRL 

GCS: E1VTM2

Cough reflex present

corneal reflex present

conjunctival reflex present

REFLEXES : right. left 

       Biceps   2+                   -

       Triceps . 2+                  2+

    Supinator  2+                 2+

       Knee        3+              3+ 

      Ankle      -                  -

      Plantar    mute    mute

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 8 , mechanical ventilator day 7

P: ENT opinion i/v/o tracheostomy

Day 4:(9/3/22) soap notes

S:- fever spikes present

O- O/E : patient is on mechanical ventilator

          PEEP- 5

          FiO2 - 40% 

          VT - 400ml

          Timp : 2.1

          VITALS:

temp- 100.9 F

BP: 120/90mm hg @ NORAD 6ml /hr

PR: 114 bpm. 

RR: 16 cpm 

spo2: 99% with Fio2 40%

GRBS: 129 mg/dl

CVS - S1, S2 heard ,no murmurs

RS. :- NVBS Present, no crepts

P/A: soft, non tender 

CNS: Pupils :B/L NSRL 

GCS: E1VTM1

Cough reflex present

corneal reflex present

conjunctival reflex present

REFLEXES :       right                  left 

       Biceps             2+                     2+

       Triceps            2+                     2+

    Supinator           2+                     2+

       Knee               3+                     3+ 

      Ankle                -                        -

      Plantar             extensor            extensor

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 9 , mechanical ventilator day 8

Day 5(10/3/22) soap notes:

S:- no fever spikes 

O- O/E : patient is on mechanical ventilator

          PEEP- 7

          FiO2 - 40% 

          VT - 400ml

          Timp : 2.6

          VITALS:

temp- Afebrile

BP: 90/50mm hg @ NORAD 8ml /hr

PR: 109 bpm. 

RR: 14 cpm 

spo2: 99% with Fio2 40%

GRBS: 181 mg/dl

CVS - S1, S2 heard ,no murmurs

RS. :- NVBS Present, no crepts

P/A: soft, non tender

CNS: Pupils :B/L NSRL 

GCS: E1VTM1

Cough reflex present

corneal reflex present

conjunctival reflex present

REFLEXES : right. left 

       Biceps   2+                   2+

       Triceps . 2+                  2+

    Supinator  2+                 2+

       Knee        2+              2+ 

      Ankle      -                  -

      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 10, mechanical ventilator day 9

Day 6 (11/3/22) soap notes

S:- no fever spikes 

O- O/E : patient is on mechanical ventilator

          PEEP- 7

          FiO2 - 40% 

          VT - 400ml

          Timp : 1.9

          VITALS:

temp- Afebrile

BP: 140/80mm hg @ NORAD 10ml /hr,vaso 2ml/hr

PR: 73 bpm. 

RR: 14 cpm 

spo2: 99% with Fio2 40%

CVS - S1, S2 heard ,no murmurs

RS. :- NVBS Present, no crepts

P/A: soft, non tender

CNS: Pupils :B/L sluggish reaction to light

GCS: E1VTM1

corneal reflex present

conjunctival reflex present

REFLEXES : right. left 

       Biceps   2+                   2+

       Triceps . 2+                  2+

    Supinator  2+                 2+

       Knee        2+              2+ 

      Ankle      -                  -

      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma /NCC ?alcohol with hypoxic encephalopathy with post CPR status day 11, mechanical ventilator day 10

P: MRI

Day 7 (12/3/22) soap notes

ICU bed 6

Day 7

http://tejaswini166.blogspot.com/2022/03/cbble-udhc-similar-cases.html

S:- no fever spikes 

O- O/E : patient is on mechanical ventilator

          PEEP- 6

          FiO2 - 30% 

          VT - 460ml

          Timp : 1.9

          VITALS:

temp- Afebrile

BP: 150/70mm hg 

PR: 79 bpm. 

RR: 17cpm 

GRBS: 149mg/dl

spo2: 99% with Fio2 30%

CVS - S1, S2 heard ,no murmurs

RS. :- NVBS Present, no crepts

P/A: soft, non tender

CNS: Pupils : NSRL

GCS: E2VTM2

cough reflex: present

corneal reflex :negative

conjunctival reflex: present

doll's eye: negative

REFLEXES : right. left 

       Biceps   3+                   3+

       Triceps . 3+                  3+

    Supinator  3+                 3+

       Knee        3+              3+ 

      Ankle      3+                 3+

      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma/?NCC with chronic hypoxic encephalopathy with post CPR status day 12, mechanical ventilator day 11

P : EEG

Day 8 (13/3/22) soap notes

S:- no fever spikes 

O- O/E : patient is on mechanical ventilator

          PEEP- 6

          FiO2 - 25% 

          VT - 400ml

          Timp : 1.9

          VITALS:

temp- Afebrile

BP: 130/90mm hg @NORAD 4ml/hr

PR: 112 bpm. 

RR: 14cpm 

GRBS: 157mg/dl

spo2: 99% with Fio2 25%

CVS - S1, S2 heard ,no murmurs

RS. :- NVBS Present, no crepts

P/A: soft, non tender

CNS: Pupils : NSRL

GCS: E2VTM2

cough reflex: present

corneal reflex : present

conjunctival reflex: present

doll's eye: negative

REFLEXES : right. left 

       Biceps   3+                   3+

       Triceps . 3+                  3+

    Supinator  3+                 3+

       Knee        3+              3+ 

      Ankle      3+                 3+

      Plantar    extensor    extensor

A: Seizures secondary to ? tuberculoma/?NCC with severe hypoxic ischemic injury with post CPR status day 13, mechanical ventilator day 12