42 F with altered sensorium secondary to encephalitis

 

    
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 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, and investigations, and come up with a  diagnosis and treatment plan.

CASE PRESENTATION

42year old female came to casuality with
        Fever since 1 week
        Vomitings since 4 days
        Loose stools since 4 days
        Involuntary movements of B/L upper and lower limbs since 1 day
History of presenting illness:
    Patient was apparently asymptomatic 1 week back, then she developed fever low grade, intermittent, relieved on medication
    Not associated with burning micturition, chills and rigors, cough and cold
    Vomitings since 4 days of bilious, non projectile, non blood tinged, filled with food particles (2-3 episodes)
    Loose stools since 4 days, low volume, watery consistency, non mucopurulent, non blood tinged. No h/o outside food consumption
    H/o 3 episodes of involuntary movements (rigidity of all four limbs), a/w uprolling of eyes, tongue biting, involuntary micturition (One episode seen by attender, other episodes seen during CT scan done outside). Post ictal state is irritable
Past history:
    K/c/o HTN since 4 months (on irregular medication)
    Not a k/c/o DM, Asthma, thyroid disorders, CAD, CVA
    Cholecystectomy done 4 years
Personal history: 
    Mixed diet, normal appetite
    Normal bowel and bladder habits
    Addictions - occasionally toddy drinker

O/E: 
    Pt is irritable 
    No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema



    Vitals: 
        Temp:104.5F
        PR:92bpm
        BP: 130/90 mmhg
        Spo2: 95% at RA
        Grbs: 211 mg/dl
    Systemic examination:
        CVS: S1, S2 heard
        RS: BAE present
        P/a: Obese, soft. Bowel sounds heard 
        CNS: patient is irritable
        No meningeal signs

Investigations:
















Chest x ray on 2/3/2023


On 3/3/23
















Diagnosis: GTCS secondary to ?acute encephalitis (bacteria>viral) ?acute gastroentritis(resolved) with HTN 
Treatment: 
IV FLUIDS- 1 NS, 1RL-75ml/hr
Inj. MONOCEF 2 g IV BD
Inj. PCM 1gm IV TID
Inj. PAN 40 mg IV OD
Inj. LEVIPIL 500mg IV BD
Inj. LORAZEPAM 4mg SOS
Inj. OPTINEURON in 100ml NS IV BD

On 3/3/23




S
C/o headache
5 fever spikes in the night

O
Pt is conscious, coherent and cooperative, oriented to person and place
BP-130/70 mmhg 
PR- 98bpm
Temp- 100.2F
RR- 21cpm
GRBS-96mg/dl

CVS- S1,S2 heard, no murmurs 
Jvp not raised 
RS- B/L Air entry present
P/A soft, non-tender 
CNS: NFND   
A
GTCS secondary to ?Acute encephalitis (viral>bacteria) acute gastroentritis(resolved) with HTN since 3 months

P
IV FLUIDS- 1 NS, 1RL-75ml/hr
Inj. MONOCEF 2 g IV BD
Inj. PCM 1gm IV TID
Inj. PAN 40 mg IV OD
Inj. LEVIPIL 500mg IV BD
Inj. LORAZEPAM 4mg SOS
Inj. OPTINEURON in 100ml NS IV BD


On 6/3/23




S
Involuntary movements of both UL and LL absent
No fever spikes


O
Pt is conscious, coherent and cooperative, not oriented to person time and place
BP-120/70 mmhg 
PR- 82bpm
Temp- 98.5F
GRBS-109mg/dl

CVS- S1,S2 heard, no murmurs 
Jvp not raised 
RS- B/L Air entry present
P/A soft, non-tender 
CNS: NFND   
A
GTCS secondary to ?Acute encephalitis (>viral ?bacteria) acute gastroentritis(resolved) with HTN since 3 months

P
IV FLUIDS- 1 NS, 1RL-75ml/hr
Inj. MONOCEF 2gm IV /BD
Inj. PCM 1gm IV SOS
Inj. PAN 40 mg IV OD
Inj. LEVIPIL 500mg IV BD
Inj. OPTINEURON in 100ml NS IV OD


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