A 70 Years Old Man Who was a Farmer By Occupation Presented to Casualty With 

Altered Sensorium Since 3 Days 

Fever Since 20 Days 

HOPI : 

Patient Was Apparently Asymptomatic Till 2014 ;

2014 - Patient Had Fever Associated with Cough for which he went to Hospital & Was Diagnosed to Have ? Pneumonia with DENOVO DM2 & Was Prescribed with OHAs ( Tab.METFORMIN & Tab.GLIMIPRIDE )

6 Months Back - Patient Had Fever Associated with Cough for Which he Went to Hospital & Said to Have High Sugars along with Lung Infection ; Got Treated & Discharged in a Hemodynamically Stable Manner.Started using insulin for Diabetes Since Then 

20 Days Back : Patient Had Fever with Cough ; For Which He went to Hospital & Suspected to Have TB But Reports Turned out to be Negative & Patient Discharged as LAMA & When He Returned Home 3 Days Back He Gradually Developed Altered Sensorium & Couldn't Recognise His Attendants

Past History :

K/C/O DM2 Since 9 Years and on Regular Medications

N/K/C/O HTN ; TB ; EPILEPSY ; ASTHMA 

Addictions : 

He Started Consumption of Alcohol at the age of 20years & It became a habit to drink 90ml per Day Till 6 Months Back

He Started Smoking Beedis at the age of 20 Years & It Became a Habit to Smoke 20 Beedis Per Day 

On Presentation : 

BP - 110/80mmHg

PR - 110/min

Temp - 102.5 F

RR - 22/min 

Spo2 - 98% @RA

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E2V2M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone - Normal in Both UL & Hypertonia in Both lower limbs

Power - 4/5 In all 4 Limbs

Reflexes - B T S K A - 2+ 

Plantars - RT - Mute & Left - Flexor


Investigations -


ECG-



S. Urea-24mg/dl

S creatine-0. 8mg/dl

S. Electrolytes -

Na+-132

K+- 3.6

Cl- 98

Ca2+ 1.20

LFT-



Hemogram-



Rbs-157mg/dl

HbA1c-6. 8%

ABG-


Chest XRay-



CSF analysis-

glucose -42

Protein -60

Cl-121

ADA-131

CSF CELL COUNT

Vol-0. 5 ml

Color- colorless

Appearance- clear

Total count-104 cells

DC-

60% lymphocytes

20% monocytes

20% neutrophils 

Others- nil

RBC- nil

20% neutrophils 

Others- nil

RBC- nil







Provisional diagnosis -

?TB meningitis


Treatment -

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @50 ml/hr

Inj. Ceftriaxone 2 GM iv stat

Then inj . Ceftriaxone 1 GM iv bd

Inj Dexa 6 mg iv stat then 

Inj. Dexa 6mg iv tid

Monitor vitals 2 nd hourly

Grbs monitoring

Strict input and output charting

Inj. Neomol 1 GM iv /sos ( if temp>101F)









16/02/23

ICU-BED NO. 3

UNIT-2

DOA-15/2/23

70 year old man c/o fever since 20 days and altered sensorium since 3 days


S-

No fever spikes

Patient obeying to commands


O-

BP - 120/70mmHg


PR - 98/min


Temp - 98F


RR - 22/min 


Spo2 - 98% @RA


Grbs-250 mg/dl


CVS - S1S2 Heard & No Murmurs 


RS - BAE + ; NVBS + 


P/A - Soft & Non Tender


CNS - 


GCS - E2V2M5


RT Pupil - Couldn't be assessed


Lt Pupil - NSRL



A-

Altered sensorium under evaluation secondary to? meningitis 

?TB meningitis


Investigations -

Hb- 12.0g/dl

TLC- 8700

PLC- 3.02LAKHS

Lymphocytes -32

Pcv-35. 2


S Urea-24mg/dl


S creatine-0. 8mg/dl


S. Electrolytes -


Na+-132


K+- 3.6


Cl- 98


Ca2+ 1.20


LFT-

Total bilirubin-0. 9

ALP-144

Total proteins-6. 2

Albumin-3. 0


Rbs-157mg/dl

HbA1c- 6.8%


P-

Ryles tube feeds-200 ml milk every 4 th hourly


100 ml water every hourly


Iv fluids NS @50 ml/hr


Inj. Ceftriaxone 2 GM iv stat


Then inj . Ceftriaxone 1 GM iv bd


Inj Dexa 6 mg iv stat then 


Inj. Dexa 6mg iv tid


Monitor vitals 2 nd hourly


Grbs monitoring


Strict input and output charting


Inj. Neomol 1 GM iv /sos ( if temp>101F)


Inj. HAI S/C according to grbs


Inj. HAI S/C according to grbs





17/02/23

ICU-BED NO. 3

UNIT-2

DOA-15/2/23


70 year old man c/o fever since 20 days and altered sensorium since 3 days


S-

No fever spikes

Patient obeying to commands

Hiccups since yesterday afternoon 


O-

BP - 110/70mmHg

PR - 66/min

Temp - 95.5F

RR - 22/min 

Spo2 - 98% @RA

Grbs-

15/2/23

8am-250mg/dl

2pm-269mg/dl

4pm-272mg/dl

8pm-278mg/dl


16/2/23

2am - 200 mg/dl

8am - 250mg /dl

2pm 265mg/dl

8pm 140mg/dl

10pm 191 mg/dl


17/2/23

2am 197 mg/dl

8am 175mg/dl


Input-2300ml

Out put-1000ml

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E3V3M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone- normal in all 4 limbs 

Power- 4/5 in all 4 limbs 


A-

Altered sensorium(resolving) secondary to meningoencephalitis secondary to tuberculosis

K/c/o DM since 9 years


Investigations -

Hb- 11.5g/dl

TLC- 11000

PLC- 3.08LAKHS

Neutrophils -85

Lymphocytes -09

Pcv 34.6

RBC count 3.08


15/2/23

S.Electrolytes -

Na-135

K-4. 3

Cl-102

Ca2+1. 12


P-

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @100 ml/hr

Inj. Dexa 6mg iv tid day 3

Inj human actrapid s/c according to GRBS 

Tab. Isoniazid 275 mg (4tabs po/od) morning

Tab. Rifampicin 550 mg (4tabs po/od morning

Tab. Pyrazinamide 1550mg (4tabs po od morning

Tab ethambutol 825 mg po od morning

Grbs 7 th hourly

Inj. neomol 1 g iv sos( if temp >101F)

Strict input output charting 

Grbs monitoring

Tab benadone 40mg po/od

Tab baclofen 10mg po/sos

Inj perinorm 10mg iv stat 

Inj pan 40mg iv/od


Beautiful Orange colored urine is seen might be due to antitubercular therapy - Rifampicin


18/02/23

ICU-BED NO. 3

UNIT-2

DOA-15/2/23

70 year old man c/o fever since 20 days and altered sensorium since 3 days


S-

C/o hiccups since 3 days

Sensorium - increased drowsiness


O-

BP - 130/80mmHg

PR - 80/min

Temp - 98.2F

RR - 20/min 

Spo2 - 98% @RA

Grbs-

15/2/23

8am-250mg/dl

2pm-269mg/dl

4pm-272mg/dl

8pm-278mg/dl

16/2/23

2am - 200 mg/dl

8am - 250mg /dl

2pm 265mg/dl

8pm 140mg/dl

10pm 191 mg/dl

17/2/23

2am 197 mg/dl

8am 175mg/dl

4pm-92mg/dl 6u HAI given

8pm- 125 mg/dl


18/02/23

2am- 168mg/dl

8am-101 mg/dl 4 units HAI given

Input-2800ml

Out put-2400ml

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - patient is drowsy not oriented to time, place and person

GCS - E2V3M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone- normal in all 4 limbs 

Power- 4/5 in all 4 limbs 

Reflexes-

                   Right.      Left


Biceps.         2+.        2+

Triceps.        2+.       2+

Supinator.    1+.       2+

Knee.             2+.         2+

Ankle.              1+.         1+

Plantar.  Decreased.   Decreased 

Investigations -

Hb- 11.6g/dl

TLC- 9300

PLC- 3.19LAKHS

Neutrophils -77

Lymphocytes -16

Pcv -34.9

RBC count 3.71

18/2/23

S.Electrolytes -

Na-124

K-3. 8

Cl-99

Ca2+-1.20

A-

Altered sensorium(resolving) secondary to meningoencephalitis secondary to tuberculosis

K/c/o DM since 9 years

P-

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @100 ml/hr

Inj. Dexa 6mg iv tid day 3

Inj human actrapid s/c according to GRBS 

Inj. Pan 40 mg iv od

Inj . NEOMOL 1g iv /sos if temp >101F

Tab. Isoniazid 275 mg (4tabs po/od) morning

Tab. Rifampicin 550 mg (4tabs po/od morning

Tab. Pyrazinamide 1550mg (4tabs po od morning

Tab ethambutol 825 mg po od morning

Tab. Benadone 40 mg po/od

Tab. Baclofen 10 mg po/sos

Grbs 7 th hourly

Strict input output charting


19/02/23

ICU-BED NO. 3

UNIT-2

DOA-15/2/23


70 year old man c/o fever since 20 days and altered sensorium since 3 days


S-

Fever spike at 7am 

Patient obeying to commands

Hiccups since 4 days 


O-

Patient is drowsy not oriented to place time and person 

BP - 110/80mmHg

PR - 106/min

Temp - 98.2F

RR - 22/min 

Spo2 - 96% @RA

GRBS 140mg/dl


18/2/23

8am 101

4pm 208

8pm 219

Grbs-

15/2/23

8am-250mg/dl

2pm-269mg/dl

4pm-272mg/dl

8pm-278mg/dl


16/2/23

2am - 200 mg/dl

8am - 250mg /dl

2pm 265mg/dl

8pm 140mg/dl

10pm 191 mg/dl


17/2/23

2am 197 mg/dl

8am 175mg/dl


Input-3000ml

Out put-3400ml

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E3V3M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone- normal in all 4 limbs 

Power- 4/5 in all 4 limbs 


A-

Altered sensorium(resolving) secondary to meningoencephalitis secondary to tuberculosis

K/c/o DM since 9 years


Investigations -

Hb- 12.9g/dl

TLC- 13100

PLC- 3.11

Neutrophils -80

Lymphocytes -14

Pcv 38.7

Mcv 39.3

RBC count 4.15

Sodium 137

Potassium 3.8

Chloride 97

Ionized calcium 1.1


15/2/23

S.Electrolytes -

Na-135

K-4. 3

Cl-102

Ca2+1. 12


P-

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @100 ml/hr

Inj. Dexa 6mg iv tid day 5

Inj human actrapid s/c according to GRBS 

Tab. Isoniazid 275 mg (4tabs po/od) morning

Tab. Rifampicin 550 mg (4tabs po/od morning

Tab. Pyrazinamide 1550mg (4tabs po od morning

Tab ethambutol 825 mg po od morning

Grbs 7 th hourly

Inj. neomol 1 g iv sos( if temp >101F)

Strict input output charting 

Grbs monitoring

Tab baclofen 10mg po/sos

Inj pan 40mg iv/od


ECG-




19/02/23

ICU-BED NO. 3

UNIT-2

DOA-15/2/23


70 year old man c/o fever since 20 days and altered sensorium since 3 days


S-

Fever spike at 11pm, 7am, 11 am  


Hiccups subsided


O-

Patient is drowsy not oriented to place time and person responding to only deep pain stimulation 

BP - 90/60mmHg

PR - 68/min

Temp - 98.2F

RR - 24/min 

Spo2 - 90 % @RA

             99%on 2l o2

GRBS 161mg/dl


Input-3000ml

Out put-3400ml


CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E2V1M3

RT Pupil - Couldn't be assessed

Lt Pupil - decreased size , non reactive to light

Tone- normal on right side 

Decreased on left side

Dolls eye positive bilateral

Jaw jerk absent 


                Right.   Left 

Biceps     2+.         -

Triceps.    2+.         -

Supinator. 1+.       -

Knee         2+.      -

ankle      1+.       -

Plantars bilateral mute

A-

Altered sensorium secondary to meningoencephalitis secondary to tuberculosis

K/c/o DM since 9 years

With ? Old pulmonary kochs

Acute infarct in ? PCA? MCA territory

With new onset left hemiplegia


P-

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @100 ml/hr

Inj. Dexa 6mg iv tid day 5

Inj human actrapid s/c according to GRBS 

Tab baclofen 10mg po/sos

Inj pan 40mg iv/od

Tab. Isoniazid 275 mg (4tabs po/od) morning

Tab. Rifampicin 550 mg (4tabs po/od morning

Tab. Pyrazinamide 1550mg (4tabs po od morning

Tab ethambutol 825 mg po od morning

Grbs 7 th hourly

Inj. neomol 1 g iv sos( if temp >101F)

Strict input output charting 

Grbs monitoring


Chest xray -


Sr . electrolytes

Na-138

K-3. 8

Cl-99

Ca2+- 1.20


MRI images




20/02/23


ICU-BED NO. 3


UNIT-2


DOA-15/2/23



70 year old man c/o fever since 20 days and altered sensorium since 3 days



S-


Fever spike at 2 am 100. 4F


Hiccups subsided


O-


Patient is drowsy not oriented to place time and person responding to only deep pain stimulation



BP - 110/70mmHg


PR - 86/min


Temp - 98.6F


RR - 22/min 


Spo2 - 97 % @RA            


GRBS 119mg/dl


Input-3400ml


Out put-1900ml



CVS - S1S2 Heard & No Murmurs 


RS - BAE + ; NVBS + 


P/A - Soft & Non Tender



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