A 55 YEAR OLD FEMALE WITH FEVER,HEADACHE AND NECK STIFFNESS

FINAL PRACTICAL- LONG CASE

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January 12,2022

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SHIVANI THOTA, 1701006181

A 55 yr old female who is house maid by occupation came with chief complaints- 

• Head ache since 20 days
• Fever since 5 days
• Neck stiffness since 5 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 20 days back then she developed 

• headache which was  insidious onset, gradually progressive, not relieved on medications ,the headache aggravated 5 days back In spite of taking medication. No aggravating factors
• Fever which was insidious onset since,intermittent,not relieved on medication.Not associated with chills / rigors,associated with neck stiffness 
• One episode of vomiting food particles 3 days ago,non projectile, non bilious, , non blood stained.

No h/o of cold 

No h/o of cough 

No h/o of loose stools 

No h/o of abdominal pain

No h/o of breathlessness, PND , orthopnoea

No h/o of burning micturition, increased frequency of micturition. 

PAST HISTORY:

No history of similar complaints in the past.

7 yrs back she gave history of CVA due to which both upper and lower limbs were paralysed,she took medication(not specified) for  6 months and recovered.

Denovo detected diabetes

She Complaints of back pain and bilateral knee pain since 2 months

Not a known case of Hypertension,Asthma,Epilepsy,

hysterectomy done  at 25 yrs 

PERSONAL HISTORY:

• Diet: Mixed
• Appetite: Normal
• Sleep:Adequate 
• Bowel and bladder:Regular 
• No addictions 
• No known allergies

FAMILY HISTORY: Insignificant 

GENERAL EXAMINATION:

The patient was examined in a well lit room,with informed consent.

Patient is conscious,coherent,Cooperative and is moderately built and malnourished 

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent 

VITALS :

Pulse rate : 75 bpm

Respiratory rate : 15 cpm 

Blood pressure : 120/70 mm of Hg 

Temperature : afebrile

CNS EXAMINATION:

Higher mental functions:

-Patient is conscious, oriented to time and place 

-Memory is intact

-Speech and language normal

 

Cranial nerve examination:

• 2 nd cranial nerve : Visual acuity - counting fingers from 6m distance 
• 3,4,6 cranial nerves : extraocular movements present, direct indirect reflexes present. 
• 5 th cranial nerve : sensations over face present 
• 7 th cranial nerve : forehead wrinkling present, able to blow cheek, able to open and close eyes, Naso labial folds normal 
• 8 th cranial nerve : hearing normal, no Nystagmus. 
• 9, 10 th cranial nerve : uvula centrally placed and symmetrical. 
• 11 th cranial nerve : trapezius and sternocleidomastoid normal 
• 12 th cranial nerve : tongue no deviation. 

Motor examination:

                                                    

1.Bulk 

Inspection and palpation normal

Right                         Left 

   - MUAC 28 cm 27.5cm 

   - mid forearm 20 cm 20 cm

   - mid thigh 29 cm     30 cm

   - mid calf 25 cm 25 cm 

    

2.Tone 

 - upper limb normal normal 

 - Lower limb     normal normal 

3.Power 

- upper limb    5/5                       5/5 

- Lower limb 5/5                       5/5     

4.Reflexes

 - knee jerk  + +

 - Ankle jerk + +

 - Biceps + +

 - triceps + +

 - Plantar normal normal 

Meningeal signs:

1. Nuchal rigidity :  present 

2. Kernig sign :  positive 

3. Brudzinski sign :  positive  

Sensory examination:Normal

Cerebellar examination : Normal

RESPIRATORY EXAMINATION:

Bilateral air entry present 

Normal vesicular breath sounds heard 

CVS EXAMINATION:

S1 and S2 heard 

No murmurs 

ABDOMINAL EXAMINATION:

Soft, non tender abdomen 

No organomegaly 

INVESTIGATIONS:

Hemogram 

Hb - 13 g/dl

TLC - 3500

N/L/E/M-60/30/2/8

PLT- 2.1 lakh per mm3

NC/NC

Fasting blood sugar- 168 mg/ dl

Hb1 AC -6.9

Urea- 38

Serum creatinine- 1.0

Uric acid - 4.9

Sodium- 141meq

Pottasium- 4.0

chloride- 105

Arterial blood gas analysis:

PH : 7.4

PCo2 : 29.1

PO2 : 88.4

HCO3 : 18

Fasting blood sugar: 168 mg/dl  

Complete urine examination:

Albumin : positive 

Sugar : nil 

Pus cells : 6-8

Epithelial cells : 3-4

RBC and casts : nil 

Renal function test :

AST : 69 IU/L

ALT : 68 IU/L

ALP : 135 IU/L

Total protein : 6.4 gm/dl

Albumin : 4.0 gm/dl

Urea : 38 mg/dl

Creatinine : 1.0 mg/dl

Uric acid : 4.9 mg /dl

Serology : Non reactive 

INVESTIGATIONS ON 12 JUNE : 

Hemogram : 

Hb- 13.1

Tlc-16,400 /mm3 

Neutrophils- 82

Leukocytes -9

Eosinophil -1

Monocyte -8

Platelet count -1.81lakh/mm3 

Arterial blood gas analysis : 

PH - 7.44

PCO2 - 28 

PO2 - 49.3

HCO3-18.7

O2 sat - 85.1

                                                                     MRI FLAIR

                                              

2D ECHO

Dengue NS1 antigen:

CSF analysis:

Sugar : 81

Protein : 12.6

Xray neck 

Xray : knee joint 

PROVISIONAL DIAGNOSIS:

Dengue fever with meningoencephalitis 

TREATMENT 

Intravenous fluids NS and RL 

Injection ceftriaxone 2 gm / ml BD 

Injection dexamethasone 6 mg intravenous TID

Injection vancomycin 1 gm intravenous sos

Injection paracetamol 1 gm intravenous SOS

Tab paracetamol 650 mg TID

Tab ecosporin 7 mg per oral OD 

Tab cremaffin 30 peroral 

Tab metformin 500 mg per oral