45 YEAR OLD MALE WITH FEVER AND ALTERED SENSORIUM

19th May 2022

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45 year old male painter by occupation (since 30years),resident at nalgonda came with 

- c/o fever since 1week

- c/o headache since 4days

HISTORY OF PRESENT ILLNESS :

Patient was apparently 15 years back, then he c/o polyuria went to hospital and was diagnosed with DM-II, since then he was started on OHA's and was under control.

- 2 years back, he c/o fever for 1month (on and off) and continous cough associated with sputum for which he went to Govt hospital and diagnosed with pulmonary TB and was given ATT course for 6 months.

- Again after 6 months, sputum samples were retested and turned out to be negative. 

- Since 1 month he c/o cough (dry) for which he went to local hospital and was prescribed some antibiotics, c/o sputum since 2 weeks (greenish, mucoid, not associated with blood). 

- Outside pleural tap was done showing exudative effusion. 

-  c/o fever since 1 week (on and off), resolving on medication, not associated with chills and rigor. 

- c/o headache since 4days in the parieto occipital region. 

- phonophobia +

- No h/o photophobia, nausea, lacrimation, vomiting, decreased appetite. 

PAST HISTORY :

- k/c/o DM-II since 15years and on Tab Glimi M2 and Tab Metformin

- h/o TB 2years ago

- No h/o HTN, asthma, epilepsy

PERSONAL HISTORY : 

He is married and have 3 daughters. 

Diet - mixed

Appetite - normal 

Bowel and bladder movements - regular 

Sleep - adequate

Occasional alcoholic weekly once to twice since 15years

Chronic smoker 3-4 cigarettes /DAY since 16years

DIETARY HISTORY :

Breakfast - 2 chapatis with curry and ragi malt

Lunch - 1cup of rice with pulses and curry 

Dinner - 2 chapatis with curry / 1 cup of rice with pulses and curry

- He consumes meat once in 2-3 weeks

- He consumes 2 eggs /day

FAMILY HISTORY : Not significant

GENERAL EXAMINATION : 

- Patient is irritable

- Pallor +

- No icterus, cyanosis, clubbing, lymphadenopathy and pedal edema

VITALS AT THE TIME OF ADMISSION :

Temp - 101.1 F

PR - 125 bpm

BP - 90/60 mm Hg

RR - 35 cpm 

Spo2 - 98% @ room air

GRBS - 216 mg/dl

SYSTEMIC EXAMINATION :

CVS - S1S2 +

RS - decreased airway entry on right side in infra axillary, infra mamammary ans infrascapular areas

P/A - soft, nontender

CNS - 

Kernig's sign +

Brudzinski's sign +

Power - 5/5 in all 4 limbs

Tone - normal in all 4 limbs

Reflexes :

- Biceps : 2+ (b/l) 

- Triceps : 2+ (b/l) 

- Supinator : 2+ (b/l) 

- Knee : 2+ (b/l) 

- Ankle : 2+ (b/l) 

- Plantar : flexor

INVESTIGATIONS :

HEMOGRAM :

ESR :

CRP :

CUE :

BLOOD UREA :

SERUM CREATININE :

SERUM ELECTROLYTES :

LFT :

SEROLOGY : NEGATIVE

PT AND INR :

APTT :

CHEST X RAY PA VIEW :

ECG : 

URINE PROTEIN/CREATININE RATIO :

- Urine protein : 33

- Urine creatinine : 95

- Ratio : 0.34

URINARY ELECTROLYTES :

- Urinary Na : 214

- Urinary K : 23

- Urinary Cl : 197

LUMBAR PUNCTURE WAS DONE :

MRI BRAIN PLAIN :

USG CHEST :

USG ABDOMEN :

2D ECHO :

MRI BRAIN PLAIN WITH CONTRAST :

HRCT THORAX :

CSF FOR CULTURE AND SENSITIVITY :

SPUTUM FOR CULTURE AND SENSITIVITY:

OPHTHALMOLOGY REFERRAL DONE I/V/O ANY OPTIC DISC CHANGES :

PULMONOLOGY REFERRAL DONE I/V/O X-RAY CHANGES :

OUTSIDE REPORTS :

PROVISIONAL DIAGNOSIS : ? TB MENINGITIS 

TREATMENT :

1. INJ DEXA 8MG IV TID

2. INJ CEFTRIAXONE 2GM IV BD

3. IVF - NS, RL @ 75ML/HR

4. INJ ZOFER 4MG IV TID

5. INJ PAN 40MG IV OD

6. INJ PCM 1GM IV SOS (IF TEMP > 101F)

7. INJ VANCOMYCIN 1GM IV STAT

8. MONITORING VITALS

SOAP NOTES

20/5/2022

DAY 1

S :

No fever spikes

O :

Patient is drowsy

BP - 80/60 mm Hg

PR - 102 bpm

RR - 21 cpm

Spo2 - 98% @ room air

GRBS - 240 mg/dL (8U HAI given)

INVESTIGATIONS :

CSF ANALYSIS :

CELLS - 15 (100% LYMPHOCYTES) 

SUGARS - 118

LDH - 16

PROTEIN - 28

CHLORIDE - 120

A :

? TB MENINGITIS

P :

1. INJ DEXA 8MG IV TID

2. INJ CEFTRIAXONE 2GM IV BD

3. IVF - NS, RL @ 75 ML/HR

4. INJ ZOFER 4MG IV TID

5. INJ PAN 40MG IV OD

6. INJ PCM 1GM IV SOS (IF TEMP >101 F)

SOAP NOTES

21/5/2022

DAY 2

S :

No fever spikes

O :

Patient is drowsy

BP - 100/70 mm Hg

PR - 108bpm

RR - 21 cpm

Spo2 - 98% @ room air

GRBS - 359 mg/DL (8U HAI given)

GRBS TRENDS : 20/5/2022

8am - 240 mg/dL (8U HAI given) 

2pm - 456 mg/dL 

8pm - 351 mg/dL (6U HAI given) 

2am - 342 mg/dL 

8am - 359 mg/dL (8U HAI given) 

CVS - s1s2+

RS - decreased airway entry on right infrascapular, infra axillary and inframammary areas

P/A - soft, nontender

CNS - NAD

INVESTIGATIONS :

HEMOGRAM :

A :

? TB MENINGITIS

? VIRAL MENINGITIS

P :

1. INJ DEXA 8MG IV TID

2. INJ CEFTRIAXONE 2GM IV BD

3. IVF - NS, RL @ 75 ML/HR

4. INJ ZOFER 4MG IV TID

5. INJ PAN 40MG IV OD

6. INJ PCM 1GM IV SOS (IF TEMP >101 F)

7. INJ ACYCLOVIR 1GM IV BD

8. TAB DOLO 650MG PO TID

9. GRBS 6TH HRLY

10. PLAN TO START ATT

SOAP NOTES

22/5/2022

DAY 3

S :

No fever spikes

O :

Patient is c/c/c

BP - 90/60 mm Hg

PR - 72bpm

RR - 21 cpm

Spo2 - 98% @ room air

GRBS - 232 mg/DL (6U HAI given)

GRBS TRENDS : 21/5/2022

8am - 359 mg/dL (8U HAI given) 

2pm - 275 mg/dL (12U HAI given) 

8pm - 160 mg/dL (4U HAI given) 

2am - 185 mg/dL 

8am - 232 mg/dL (6U HAI given) 

CVS - s1s2+

RS - decreased airway entry on right infrascapular, infra axillary and inframammary areas

P/A - soft, nontender

CNS - NAD

INVESTIGATIONS :

HEMOGRAM :

BLOOD UREA :

PHOSPHORUS :

SERUM ELECTROLYTES :

SERUM CREATININE :

A :

? TB MENINGITIS 

P :

1. INJ DEXA 8MG IV TID

2. INJ CEFTRIAXONE 2GM IV BD

3. IVF - NS, RL @ 75 ML/HR

4. INJ ZOFER 4MG IV TID

5. INJ PAN 40MG IV OD

6. INJ PCM 1GM IV SOS (IF TEMP >101 F)

7. TAB ATT 3TABS/DAY

8. TAB DOLO 650MG PO TID

9. GRBS 6TH HRLY

SOAP NOTES

23/5/2022

DAY 4

S :

No fever spikes

O :

Patient is c/c/c

BP - 100/60 mm Hg

PR - 76bpm

RR - 21 cpm

Spo2 - 98% @ room air

GRBS - 184 mg/dL (6U HAI given)

GRBS TRENDS : 22/5/2022

8am - 232 mg/dL (6U HAI given) 

2pm - 320 mg/dL (14U HAI given) 

8pm - 321 mg/dL (6U HAI given) 

2am - 253 mg/dL 

8am - 184 mg/dL (6U HAI given) 

CVS - s1s2+

RS - decreased airway entry on right infrascapular and inframammary areas crepts +

P/A - soft, nontender

CNS - NAD

INVESTIGATIONS :

HEMOGRAM :

A :

? TB MENINGITIS 

P :

1. INJ DEXA 8MG IV TID

2. INJ CEFTRIAXONE 2GM IV BD

3. IVF - NS, RL @ 75 ML/HR

4. INJ ZOFER 4MG IV TID

5. INJ PAN 40MG IV OD

6. INJ PCM 1GM IV SOS (IF TEMP >101 F)

7. TAB ATT 3TABS/DAY

8. TAB DOLO 650MG PO TID

9. GRBS 6TH HRLY

SOAP NOTES
24/5/2022
DAY 5
S :
No fever spikes

O :
Patient is c/c/c
BP - 90/60 mm Hg
PR - 80 bpm
RR - 21 cpm
Spo2 - 98% @ room air
GRBS - 208 mg/dL (6U HAI given)

GRBS TRENDS - 23/5/2022
8am - 184 mg/dL (6U HAI given)
8pm - 492 mg/dL (6U HAI given)
2am - 300 mg/dL
8am - 208 mg/dL (6U HAI given)

FEVER CHART :

CVS - S1S2 +
RS - BAE+
P/A - soft, nontender
CNS - NAD

INVESTIGATIONS :

HEMOGRAM :

A :
? TB MENINGITIS

P :
1. INJ DEXA 8MG IV TID
2. INJ CEFTRIAXONE 2GM IV BD
3. IVF - NS, RL @ 75 ML/HR
4. INJ ZOFER 4MG IV TID
5. INJ PAN 40MG IV OD
6. INJ PCM 1GM IV SOS (IF TEMP >101 F)
7. TAB ATT 3 tabs/DAY
8. TAB DOLO 650MG PO TID
9. TAB BENADON 40MG PO OD
10. GRBS - 6TH HRLY