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A CASE of 48 yr old male with fever , paraperisis and altered sensorium

E-LOGS MEDICINE

Hi , I am Soumyadeep Biswas a medical student. This is an E-Log that would help us to understand the patient centered approach for learning medicine. This E-Log has been created after taking consent from the patient and their relatives. Hope you gain some knowledge after going through the case.




July 2 , 2021

48 YR OLD MALE PATIENT DIAGNOSED WITH ALTERED SENSORIUM SECONDARY TO MENINGOENCEPHALITIS


CHIEF COMPLAINTS

  • Fever since 10 days

  • Altered sensorium  since 5 days

  • Weakness of bilateral lower limbs - 3days 


  • H/O of Oliguria since 3days


HISTORY OF PRESENT ILLNESS 


  • Patient was apparently  asymptomatic 1yr back , then he developed decreased urine output for which they admitted in hospital and Foley’s Catheter was placed , then he was diagnosed with Prostatomegaly with Rt renal calculi.


  •  Since 10 days patient has high grade fever on and off  not associated with vomiting/loose stools/cough.


  • Altered sensorium since 5 days.

  • Since 3 days patient had bilateral lower limb  weakness , difficulty to move B/L lower limbs associated with decreased urine output since 3 days. 


PAST HISTORY


  •  No H/O  hypertension , diabetes , asthma, TB , epilepsy


  • H/O HIV 10 yrs back


PERSONAL HISTORY


Diet - mixed


Appetite  - normal


Bowel , bladder movement - regular


Sleep - adequate


Regular smoker , alcoholic (occasionally 250ml)


FAMILY HISTORY


No relevant family history


GENERAL EXAMINATION


Patient is conscious , not coherent , not oriented to time place and person.


VITALS


BP: 130/90


Temperature: 101°F    


PR: 102 bpm 


Spo2: 98%










10-06-21


VITALS


Bp: 120/80 


PR: 100bpm








12-06-21


VITALS


Temperature:101.7 °F 


PR: 105bpm






  • Pallor - absent


  • Icterus - absent 


  • Cyanosis - absent


  • Koilonychia - absent 


  • Lymphadenopathy  - absent 


  • Clubbing  - absent 


  • Oedema - absent 


SYSTEMIC EXAMINATION 


CVS


  • Cardiac sounds S1 and S2 heard 


  • No cardiac murmurs heard


  • Thrills are absent




RESPIRATORY


  • Bilateral air entry with normal vesicular breath sounds heard 


  • No wheeze heard 


  • No dyspnea 


  • Trachea is central


ABDOMEN 


  • Shape of abdomen - Obese


  • No tenderness elicited


  • Palpable mass present


  • Free fluid is present 


  • Bruits can be heard


  • Liver and Spleen - Not palpable 


  • Bowel sounds - Present









CNS


  • Incoherent


  • Neck stiffness  


  • Kernig’s sign - Positive


  • Sensory -  cannot be examined


  • Motor -


                     R            L


Tone    UL   N            N (normal)    


             LL  decreased    decreased 


Power  UL   5/5            5/5


              L/L  1/5            1/5


REFLEXES


RT SIDED


biceps 2+ , triceps 2+ ,supinator 2+,knee absent, ankle absent 


LT SIDED 


biceps 1+, triceps 2 + , supinator 2+ , knee absent  ankle absent


No cerebellar signs 


PROVISIONAL DIAGNOSIS 


Altered sensorium secondary to Meningoencephalitis (infarct in splenium of corpus collosum)


INVESTIGATIONS 


(10-06-21)


CSF





RFT









BLOOD SUGAR








MRI BRAIN PLANS






CX-RAY 


ECHOCARDIOGRAM 





 




TREATMENT 



1 .inj PAN 40mg IV /OD


2 . IV NS/RL 75 ml/hr


3 .inj Thiamine 1 amp in 100ml NS IV/BD


4. Inj Optioneuron 1 amp in 100ml NS IV/OD


5 . Bp /PR/ Spo2 , temp monitoring 4th hourly


6. Tab ECOSPORIN Av 75/40mg OD



 TREATMENT UPDATE


  • inj PAN 40 mg /OD


  • IVF NS/RL 75 ml/hr


  • inj THIAMINE 100ML NS TID


  • inj OPTINEURON 10ML OD


  • TAB  CEFTRIAXONE 2gm /IV/BD


  • TAB ECOSPORIN -AV 75/40 mg /OD


  • GRBS charting 6th hourly



UPDATE  


(10-06-21)


  • Patient condition is improved , oriented to time place and person


  • By history it is found that , he is HIV positive since 10 + yrs


  • CSF analysis showed raised protein 2.9 gms and decreases glucose 28 mg/dl


  • CSF sent for culture.


  • Patient is started on inj  Ceftriaxone 



UPDATE  


(12 -06-21)


  • Patient is oriented to time , place and person


  • CSF analysis shows 40 percent lymphocytes 


  • CSF culture shows diptheroids


  • TB is considered one of differential diagnosis 


  • Anti tubercular therapy is yet to start


VITALS 


Temperature: 101.7 °F 


PR: 105 bpm












UPDATE 


(17-06-21)








TREATMENT UPDATE


Same treatment continued


+

Started on ATT  -HRZE REGIMEN 4 TAPO/OD


Started on HRT -TLD REGIMEN 1TAB PO /OD












































Comments

  1. caregiver7careseeker13 July 2021 at 08:22

    Please remove the patient identifiers visible in the CSF biochemistry report! It's much better to not upload images of reports. Only clinical images and radiology images need uploading and laboratory images showing findings such as peripheral smear or culture growth or histopathology.

    ReplyDelete

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