64M with altered sensorium sec to meningoencephalitis with TB with renal AKI with DM

DOA :28/12/2022
Discharge 
Date:09thJan2023 
Ward: AMC
Unit:3

Diagnosis
ALTEREDSENSORIUMSECONDARYTOMENINGOENCEPHALITIS...?TB BILATERAL LT>RT SIDED PNEUMONIAE
BILATERALFIXEDFLEXIONDEFORMITYSINCE2YEARS PRE RENAL AKI(RESOLVING)
K/C/O DM SINCE 6 YRS

Case History and Clinical Findings
CHIEF COMPLAINTS:-
UNABLETOTALKSINCEYESTERDAY LACK OF APPETITE SINCE 3 DAYS HICCUPS SINE 7 DAYS
LOOSESTOOLS5DAYSBACK-RELIEVEDONMEDICATION FEVER EPISODE 4 DAYS BACK

HOPI:-
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN HE DEVELOPED DIARRHOEA5EPISODESPERDAYFOR1DAYWHICHRELIEVEDONMEDICATION.THENHE DEVELOPED HICCUPS SINCE 7 DAYS AND ANOREXIA SINCE 3 DAYS.
SINCE YESTERDAY HE IS UNABLE TO TALK
NOH/OOFSOB,COUGH,PALPITATIONS,LOC,GIDDINESS,INVOLUNATRYPASSAGEOF STOOLS AND URINE

PAST H/O:-
K/C/ODMTYPE2SINCE6YRSONMEDICATIONT.METFORMINODANDT.GLIMIPERIDEOD N/K/C/O HTN, ASTHAMA, EPILEPSY, CVA, CAD, TB

PERSONALH/O:- DIET- MIXED
APPETITE - INADEQUATE
BOWEL AND BLADDER MOVEMENTS - REGULAR ADDICTIONS-OCCASIONALINTAKEOFALCOHOL OCCASIONAL INTAKE OF GUTKHA

FAMILY H/O:-INSIGNIFICANT


GENERAL EXAMINATION:-
PATIENTISCONSCIOUS/COHERENT/COOPERATIVE PALLOR +
NOSIGNSOFICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA VITALS:
TEMP-AFEBRILE BP-120/80MMHG PR- 115BPM
RR- 17CPM
SPO2- 98% @ ROOM AIR


SYSTEMIC EXAMINATION:-
CVS:-S1S2HEARD,NOMURMERS RESP:- BAE +, NVBS +
CNS:- RT LT TONE:ULHYPON LL HYPO N
POWER:UL0/53/5 LL 0/5 2/5
REFLEXESCANNOTBEELICITED COURSE IN THE HOSPITAL:
PTWASADMITTEDON28/12/22WITHC/OFEVER-LOWGRADE,INTERMITTENTLASTEDFOR 1 DAY,RELIEVED ON MEDICATION THEN HE DEVELOPED HICCUPS:7 DAYS AND LOSS OF APPETITE:3 DAYS WITH UNABLE TO TALK:3 DAYS,ALTERED SENSORIUM:7 DAY
HISCONDITIONONPRESENTATIONWASGCSE4V1M4ALLNECESSARYINVESTIGATIONS AND IMAGING WAS DONE,MRI WAS DONE AND MRI SHOWED CEREBRAL ATROPHY
.INVESTIGATION REVEALED MILD HYOPONATREMIA WHICH WAS CORRECTED. OPHTHALMOLOGYREFERRALTAKENI/V/ORAISEDICTANDSHOWEDNORAISEDICT CHANGES AND ADVISED AND FOLLOWED.
REFERREDTOANAESTHESIAFORLUMBARPUNCTUREWHICHWASDONEUNDERSTRICT ASEPTIC CONDITIONS I/V/O NECK RIGIDITY SUSPICIOUS OF MENINGO-ENCEPHALITIS.CSF PICTURE SUGGESTIVE OF TB MENINGO-ENCEPHALITIS AND STARTED ON ATT.
ORTHO REFERRAL WAS TAKEN FOR FIXED FLEXION DEFORMITY OF B/L LOWER LIMBS.PHYSIOTHERAPY ADVISED.HIS CONDITION FURTHER DETERIORATED TO GCS- E2V1M4 AFTER APPROPRIATE TREATMENT RECIEVED HIS GCS AGAIN IMPROVED TO CURRNETCONDITIONTOE4V5M6.HYPONATREMIACORRECTED.PATIENTISDISCHARGED IN A HEMODYNAMICALLY STABLE STATE.

Investigation
MRI BRAIN:-
NO SIGNS OF RAISED ICT
TINYACUTEINFARCTINRIGHTTEMPORALLOBEONMEDIALASPECT DIFFUSE CEREBRAL ATROPHY- AGE RELATED

USGABDOMENON28/12/22:- LIVER :- NORMAL PANCREAS:- NORMAL
RIGHTKIDNEY:-9.3X4.2CM,NORMAL LEFT KIDNEY :- 8.9 X 3.8 CM, NORMAL
IMP:- NO SONOLOGICAL ABNORMALITIES DETECTED


CHEST XRAY ON 29/12/22:-


NODUALROPACIFICATIONSSEENINUPPERANDMIDZONEOFRIGHTLUNGANDALL ZONES OF LEFT LUNG LIKELY INFECTIVE CAUSE

CYTOLOGY OF CSF FLUID ON 29/12/22:-
SMEARSHOWSSCATTEREDNEUTROPHILS,FEWLYMPHOCYTESAGAINSTPALE EOSIONPHILIC BG
NO E/O ATYPICAL CELLS
IMP: NEGATIVE FOR MALIGNANCY


CSF CULTURE AND SENSITIVITY REPORT ON 31/12/22:
GRAMSTAIN:FEWLYMPHOCTESANDFEWGRAMPOSITIVEBACILLISEEN(SKINFLORA) ZN STAIN:- NO AFB SEEN
NOGROWTHAFTER48HRSAFTERAEROBICINCUBATION OPHTHAL REFERRAL:
ADVISEDFUNDOSCOPY-SHOWEDNOFEATURESOFRAISEDICT ANAESTHESIA REFERRAL:
LUMBAR PUNCTURE
CSFPICTURESUGGESTIVEOFTBMENINGO-ENCEPHALITISANDSTARTEDONATT. HEMOGRAM
ON28/12/22: HB:10.2 TLC:7800 PLT:4.72 30/12/2022: HB:9.5 TLC:6100 PLT:4.13 31/12/22: HB:10.5 TLC:13,000 PLT:5.02 1/1/23: HB:10.7 TLC:12,600


PLT:4.36 5/1/23:
HB:10.6 TLC:13,300 PLT:3.34 6/1/23:
HB:11 TLC:15,600 PLT:2.52 7/1/23:
HB:10.5 TLC:24000 PLT:2.60 8/1/23:
HB:9.2 TLC:20,000 PLT:2.08 9/1/23:
HB:8.8 TLC:18,100 PLT:2.1

Treatment Given(Enter only Generic Name)
NEB WITH IPRAVENT 8TH HRLY AND BUDECORT 12TH HRLY
IV FLUIDS NS @100ML/HR
INJ THIAMINE 100 MG IV/TID IN 100ML NS
ATT RT/OD FDL3TABS/DAY
TAB BENADON 40MG RT/OD
SYPLACTULOSE15MLRT/BD ORTHO REFERRAL:
ADVISEDPHYSIOTHERAPY-PASSIVEMOVEMENTS,STRECTHINGMOVEMENTS,ALLLIMBS MOBILIZATION
RT FEEDS : 100ML MILK+ 3-4 SCOOPS PROTEIN POWDER 4TH HRLY


PASSIVE PHYSIOTHERAPY
VITAL MONITORING 6TH HRLY
FREQUENT POSITION CHANGE
TOLVAPTAN 15 MG PO/OD
Advice at Discharge TAB.BICOZINCPO/ODX5DAYS TAB.ATT PO/OD 3TABS/DAY TAB.BENADON 40MG PO/OD
TAB.TOLVAPTAN30MGPO/ODX4DAYS SYP.LACTULOSE 15ML PO/HS X5DAYS

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