MEDICINE PRACTICAL EXAMINATION

 MEDICINE CASE DISCUSSION 

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January 12,2022

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SHIVANI THOTA,134

CASE:    A 47 old man with fever with chills and neck rigidity

fever 

headache 

Slurring of speech

Gait abnormality 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days back,then he 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.

PAST HISTORY:

Medical history- 

The patient is not a known case of Diabetes Mellitus, tuberculosis, asthma, epilepsy, CAD

She had been diagnosed with hypertension 3 years ago, for which she is not on any medication.

Surgical history-

There is no relevant surgical history for this patient 

PERSONAL HISTORY

Diet- Mixed 

Appetite- decreased since 3 days

Sleep- adequate

Bowel and Bladder movements-  Urine output decreased on day 1 of admission  

Addictions- Patient consumes alcohol daily for the past 20 years (750ml per day). He stopped consuming since 1 month

FAMILY HISTORY- not significant 

GENERAL EXAMINATION:

With prior consent, patient was examined in a well lit room, lying down on the bed. She is thin built and moderately nourished.

The patient was conscious, coherant, and co-operative and well oriented to time, place and person.

Pallor- Present

Icterus- Present

Clubbing- Absent

Cyanosis- Absent

Lymphedenopathy- Absent

Edema- Absent

Koilonychia:absent 

VITALS- 

Temp :  101  F 

PR : 90 bpm

BP : 140/80 mmhg 

RR : 18 

SPO2 : 98 % at RA 

GRBS-122 mg/dl

SYSTEMIC EXAMINATION:

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- normal

2- visual acuity - normal

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:            flexor                    flexor

Meningeal signs-

Neck stiffness -present on Day 1 and 2

Decreased on Day 6

Kernigs sign - positive on day 1 and 2

Absent on day 6

SENSORY EXAMINATION:

CEREBELLUM EXAMINATION:

• Able to do finger nose test.
•  Dysdiadokinesia present on day 2
• No rebound tenderness 
• Gait: Normal
• Romberg's sign: Negative

AUTONOMIC NERVOUS SYSTEM:

• No abnormal sweating
• No resting tachycardia

RESPIRATORY SYSTEM :Bilateral air entry present,normal vesicular breath sounds

Scaphoid abdomen

CVS :S1 and S2 heard, no murmurs heard .

ABDOMINAL EXAMINATION :soft and non tender

INVESTIGATIONS

                               

                                                            MRI BRAIN

                                                   

                            CHEST X-RAY

                                                
   

              URINE CULTURE REPORT

                                                OPHTHALMOLOGY CONSULTATION

                       Fever charting

                                 ECG

PROVISIONAL DIAGNOSIS:

Meningitis?

 

TREATMENT

On Day 1;

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 Day 2:

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 Day 3:

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 Day 4:

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 Day 5:

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 Day 1:

LP done on 24-3-22 at 2 am - showing around 450 cells? Lymphocyte predominant,

Glucose - 32Protein - 195

Chloride - 120

GRBS at time of LP - 112mg/dl