47 year old male with altered sensorium fever headache

" 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 comments on comment box are 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.

(I ve made this blog with help of https://08arshewarpavankumar.blogspot.com/)

 • Courtesy video amd image references 

Time line of events - 

■1997  :patient married at 22 years 

■1998: he started smoking and drinking on occasional purposes

■1998-2000: he had two sons and one of the son died due to dog bite following which alcohol consumption was more

■ 2000-2022 : uneventful patient was alright without any complaints

■ 2022, 24th march : 

Patient was apparently asymptomatic 3 days back then developed high grade fever with  chills, intermittent and relieved with meds and associated with severe headache since 3 days ,throbbing in nature

Not associated with burning micturition , vomiting's, loose stools, sob, cough , chest pain, bleeding manifestations

There are complaints of altered sensorium since 3 hours unable to talk and walk properly so was brought to casualty on 24th march

No urine output since morning

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 

Sleep-inadequate

Bowel-regular

Bladder - decreased

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.

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,personMemory : immediate,recent, remote intactSpeech: normalNo 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+

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 presentNo rebound tenderness Gait: could not be elicited

AUTONOMIC NERVOUS SYSTEM:

No abnormal sweatingNo 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