case 31- 48M fever , paraparesis


A CASE of 48 yr old male with fever , paraperisis and altered sensorium
July 02, 2021
E-LOGS MEDICINE
 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

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