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A 47 year old man with fever, chills and rigors

CHIEF COMPLAINTS:

Patient came to the hospital with the chief complaints of - fever , headache , altered sensorium.

HOPI:

Patient was apparently asymptomatic 5 days back,  then he developed,

High grade fever which was acute in onset associated 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 history of  burning micturition,  vomiting, loose stools,  SOB,  cough ,chest pain, bleeding manifestations.

PERSONAL HISTORY:

Diet- mixed
Appetite- Normal
Sleep - adequate
Bowel - regular
Bladder - Normal
Patient is an 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: Prior Consent was taken. 

Patient is oriented to time ,place and person
Poorly built and poorly nourished.
Examined in 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, on Day 1
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:
Crude touch. + +

Pain. + +

Temp. + +

Fine touch-- present

Vibration. + +

Position. + +

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 on day 1:
- Few lacunar infarcts in medulla on left side.No f/o raised ICT on MRI 





Chest x-ray on day 1:



Ultrasound report on day 1;




ECG on day 1:




Opthal- fundoscopy i/v/o any raised ICT for  LP




Investigations on Day 1:


Blood culture report on day 3


Urine culture report on day 3




Fever charting


LUMBAR PUNCTURE: On Day 1:
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


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.




Provisional diagnosis- meningitis?

Reference log:
https://divyaraju26.blogspot.com/2022/03/47-year-old-male-with-fever-headache.html

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