FINAL PRACTICAL- SHORT CASE
HT NO: 1701006192
A 55 yr old female who is house maid by occupation came with chief complaints of
- 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 and 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 allopathy medicine for 6 months and recovered.
Denovo detected diabetes
Not a known case of Hypertension, Asthma, Epilepsy,
Hysterectomy done at 25 yrs of age.
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 prior informed consent.
Patient is conscious, coherent, cooperative and is moderately built and malnourished
No signs of Pallor , Icterus ,Cyanosis ,Clubbing , Lymphadenopathy and Edema
VITALS :
Afebrile
Pulse rate : 75 bpm
Respiratory rate : 15 cpm
Blood pressure : 120/70 mm of Hg
SYSTEMIC EXAMINATION:
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
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
Dengue NS1 antigen
CSF analysis :
Glucose : 81
Protein : 12.6
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
RFT:
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
X- ray neck:
MRI - FLAIR: Enhancements seen in leptomeninges and sulcal spaces in bilateral parietal and occipital areas, most likey meningitis.
PROVISIONAL DIAGNOSIS:
Dengue fever with meningoencephalitis
TREATMENT
9 th and 10 th June 2022 :
Injection ceftriaxone 2 gm / ml BD
Injection dexamethasone 6 mg intravenous TID
Injection vancomycin 1 gm intravenous sos
Injection paracetamol 1 gm intravenous TID
Tab ecosporin 7 mg per oral OD
Tab cremaffin 30 peroral
INVESTIGATIONS ON DAY 2:
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
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
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