" 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
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
- Biceps: 2+ 2+
- Triceps: 2+ 2+
- Supinator: 2+ 2+
- Knee: 2+ 2+
- 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
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