A 47 year old man with fever, chills and rigors
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CHIEF COMPLAINTS:
Patient came to the hospital with the chief complaints of - fever , headache , altered talking ,walking and confusion.
HOPI:
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.
PERSONAL HISTORY:
Diet- mixed
Appetite- decreased since 3 days
Sleep - inadequate
Bowel - regular
Bladder - decreased urine output on 24-3-22
Smokes ,montly once and was a occasional drinker but stopped 1 month back.
PAST HISTORY:
N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy
ADDICTIONS:
No significant drug history
FAMILY HISTORY : not significant
GENERAL EXAMINATION:
Patient is oriented to time ,place and person
Poorly built and poorly nourished.
Examined under a well lit room.
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,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
Biceps: 2+ 2+
Triceps: 2+ 2+
Supinator: 2+ 2+
Knee:. 2+ 2+
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
MRI Impression (24-3-22)
- Few lacunar infarcts in medulla on left side.No f/o raised ICT on MRI
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:
Glucose - 32
Protein - 195
Chloride - 120
GRBS at time of LP - 112mg/dl
Provisional diagnosis- meningitis?
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