55 years old lady with dengue fever meningoencephalitis
LONG CASE - FINAL MBBS PART 2 PRACTICAL EXAMINATION.
Name : MD. PARVEZ AHMED ANSARI
REG. NO.: 1701006111
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent.
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
Your valuable inputs on comment box is welcome
* I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CASE REPORT ::
A 55year old female patient who is housewife hailing from nalgonda was brought to the hospital with
CHIEF COMPLIANTS ::
* Fever since 5 days .
* Neck stiffness since 5 days.
HISTORY OF PRESENT ILLNESS ::
Patient was apparently asymptomatic 5 days back and was able to perform her regular activities without any difficulty then she experienced Fever which is
sudden onset
Continuous
Associated with chills and rigor
Associated with generalised body pains and headache .
Associated with 1 episode of vomiting which is non projectile, non bilious , food particles as content and non foul smelling. Not associated with abdominal pain and loose stools.
Relieved on medication.
Neck stiffness which is
Sudden onset
Associated with decreased range of movements at neck
No H/O trauma
Not relieved on rest and painkillers.
No H/O Burning micturition.
PAST HISTORY ::
No similar compliants in the past.
Not a known case of hypertension
Tuberculosis,
epilepsy
asthma
and CAD.
There is H/O CVA with compliants of bilateral upper & lower limb paralysis 7 years back for which she was treated and recovered in 1month .
Surgical H/O - Hysterectomy 25years back.
PERSONAL HISTORY
Diet - Mixed
Appetite - reduced
Sleep - adequate
bladder - regular
Bowel movements - constipation since 3 days
No addictions and no known allergies.
FAMILY HISTORY
Not significant.
GENERAL EXAMINATION
Patient is conscious, coherent, and cooperative.
Moderately built and nourished.
Well oriented to time, place and person.
Patient was examined in supine position in a well lighted room after taking consent and explaining the procedure.
PALLOR - absent
ICTERUS - absent
CLUBBING - absent
CYANOSIS - absent
LYMPHADENOPATHY - absent
EDEMA - absent
VITALS ::
Temperature - 99⁰F
Pulse rate - 98 beats per minute , normal volume , character and normal vessel wall , no radioradial and radiofemoral
delay .
Respiratory rate - 20cycles per minute
Blood pressure - 110/70 mmHg in both arms.
O2 sat. - 96% at room air.
CNS :
Dominance - Right handed
Higher mental functions
• conscious
• oriented to person and place
• memory - able to recognize their family members
• Speech - Normal
Cranial nerve examination
• 1 - sense of smell present.
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present on both sides
• 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present
No dysphagia and hoarsness
• 8- able to hear
• 9,10- position of uvula visualized
• 11- sternocleidomastoid contraction present
• 12- no tongue deviation
Motor system
Attitude - Normal
Tone - Normal tone on right side(UL,LL)
Normal tone on left side(UL,LL)
Bulk - Rt. Lt.
Arm 26cm. 26cm
Forearm 19cm 19cm
Thigh 42 cm. 42cm
Leg 28cm. 28cm
Power
Right. Left
UL 5/5 5/5
LL. 5/5 5/5
Reflexes Right Left
Biceps + + ++
Triceps + + ++
Knee jerk ++ ++
Ankle jerk ++ ++
Babinski Flexion Flexion
Corneal reflex present on both sides
Light reflex present on both sides
(Direct and indirect)
Sensory system: Normal
Cerebellar signs :
Knee - heel incoordination - No
Finger - nose incoordination- No
Meningeal signs -
Neck stiffness present .
Kernig's sign - positive
Brudzinki sign - positive
Biceps
Triceps
Knee
Power.
Ankle
Babinski
EXAMINATION OF OTHER SYSTEMS
RESPIRATORY SYSTEM:
Chest symmetrical, No paradoxical movements, Normal vesicular breath sounds heard,
No abnormal/added sound
CARDIOVASCULAR SYSTEM:
S1 S2 Heart sounds – normal
No thrills/murmurs
ABDOMINAL EXAMINATION
Abdomen is non tender,soft, ,No organomegaly, No ascites.
Provisional diagnosis:-
Dengue fever with meningoencephalitis.
Denovo diabetes mellitus type 2.
ECG:
MRI brain :
2Decho:-
Treatment:-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
On day 2 :-
Patient is conscious, coherent, cooperative.
Vitals:-
Temperature: 99°F
Pulse rate: 76bpm
Resp rate:15cpm
BP:130/90mmhg
Spo2:96%
GRBS- 197mg/dl
Treatment-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
Oint.Diclofenac for thigh pain
On day 3:-
Patient is conscious, coherent, cooperative.
Vitals:-
Temperature: 99°F
Pulse rate: 78bpm
Resp rate:16cpm
BP:120/90mmhg
Spo2:96%
GRBS- 190mg/dl
Investigations:-
Treatment-
Inj. CEFTRIAXONE 2 gm/ BD
Inj.DEXA 6mg/iv/tid
Inj . Vancomycin 1gm/iv
Inj. Pcm 1gm/iv
Tab . Pcm 650 mg
Tab. Ecospirin 75 mg /po/od
Tab. Atorvas 10 mg /po/od
Syp. Cremaffin plus 30ml/po
Oint.Diclofenac for thigh pain
Inj.pan 40 mg iv /od
Tab. Naproxen 250 mg po/tid.
Flexbenz gel for L/A on thighs

Comments
Post a Comment