Long case - final practical

Hall ticket no. 1701006160

Long case 

       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 findings , investigations , and come up with diagnosis and treatment options

Following is the view of my case :

FEVER WITH HEADACHE

A 55 year old female, resident of nalgonda district, labourer by occupation came to hospital on 9 th June 2022.

C/O :   

1. Headache since 20  days 
2. Fever  since 5 days 
3. Neck stiffness since 5 days 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 20 days back, then she developed 

1. Headache : insidious onset, gradually progressive, not relieved on medication (medicine taken from a local doctor) The headache aggravated 5 days back I spite of taking medication. No aggravating factor. 
2. Fever : insidious onset, since 5 days, intermittent fever , not relieved on medication she took at home. Not associated with chills / rigors. 
3. Neck stiffness : insidious onset, gradually progressed. 
4. Vomiting : one episode, 3 days back, non projectile, non bilious, food as content, non blood stained. 

No abdominal pain, diarrhea, cold, cough. 

PAST HISTORY :

-Paralysis of bilateral upper and lower limbs 7 years back. She was treated for paralysis in various hospitals. She recovered in 6 months. 

-Back pain since 2 months. Takes medicine when it's severe. 

-No h/o hypertension, asthma, epilepsy, tuberculosis. 

-Denovo detected diabetes. 

-No h/o surgeries. 

PERSONAL HISTORY : 

Diet : mixed 

Appetite : normal 

Bowel / Bladder : regular 

Sleep : adequate 

Addictions : none 

FAMILY HISTORY : 

Not significant. 

GENERAL EXAMINATION : 

-Patient is explained about the examination and consent taken. 

-Patient is conscious, coherent, cooperative 

-No signs of pallor, Icterus, cyanosis, clubbing, lymphadenopathy and pedal edema. 

VITALS : 

Pulse rate : 75 bpm

Respiratory rate : 15 cpm 

Blood pressure : 120/70 mm of Hg 

Temperature : afebrile 

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 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 : Ns 1 antigen 

 

CSF analysis : 

Sugar : 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 

Renal function test : 

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 

Xray neck : 

Xray : knee joint 

MRI of brain  : 

X ray of chest : 

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 12 JUNE : 

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