55yrs female with fever , head ache and neck stiffness

 

Sahithi nalabolu 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
 
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

Hall ticket number:1701006124

Final exam long case:

Case presentation:

A 55yrs old female house maid by occupation came to the hospital on 9th june with

Chief complaints:

•Fever since 5days 

•Headache since 5days

• neck stiffness since 4days

History of present illness:

Patient Was apparently asymptomatic 5days ago then she developed fever sudden in onset continuous type and relieved on medication associated with generalized body pains

Fever was not associated with chills and rigors.

Headache since 5days  insidious in onset and throbbing type and progressive  relieved on medication  .

 Neck stiffness since 4days.

History of  vomiting 3days back 1episode non projectile non bilious content food particles.  

 No history of photophobia , seizures.

No history of cough , cold, loose stools , abdominal pain, sob

No history of burning of micturition.

Past history:

No history of similar complaints in past.

Not a known case of diabetes,Hypertension ,Asthma , tuberculosis, Thyroid.

Hysterectomy done 25yrs ago.

Family history:

No Similar complaints in family

No history of Dm , hypertension. 

Personal history:

Diet: mixed 

Appetite: decreased 

Sleep: Adequate 

Bowel and bladder: regular 

No addictions and allergies. 

General examination:

Patient is conscious coherent co operative well oriented to time, place ,person.

She is moderately built and well nourished. 

No pallor,icterus, cyanosis, clubbing ,lymphadenopathy,edema.






Vitals:

Temperature:99°F

Bp:75bpm

PR:75bpm

RR:17cpm

Spo2:96%


Systemic Examination:-

CENTRAL NERVOUS SYSTEM EXAMINATION.


HIGHER MENTAL FUNCTIONS:

 Patient is Conscious, well oriented to time, place and person.

cranial nerves -

1-sense of smell - present

2-Direct and indirect light reflex present.

3-3 and 4 and 6- no ptosis , squint , nystagmus.

5-corneal reflex present 

7-fore head wrinkles ( frontalis)
   Eye closure (orbicularis occuli)
   Showing teeth (orbicularis oris)
    Blowing ( buccinator)
     Taste sensation over anterior 2/ 3 of      tongue are normal.

8- hearing normal 

9and 10-  no deviation of ulva 
                    

11-shrugging of shoulders present 

12-no tongue deviation.


Motor system

                              Right.                  Left

BULK 
Upper limbs.        N.                         N
Lower limbs         N.                         N

TONE
 Upper limbs.       N.                        N
 Lower limbs.      N.                        N

POWER
 Upper limbs.      5/5.                    5/5
 Lower limbs      5/5.                    5/5


Superficial reflexes:

Coneal reflex. +
Conjunctival reflex +
Abdominal reflux   +

 Deep reflexes 
                         Right                  left
 
Biceps.              +                             +
Triceps.           +                             +
Knee                  +                         +
Ankle.             +                             +



Gait is normal

No involuntary movements

Meninges :


Neck stiffness - positive 
Kerning sign - positive 
Brudzinsk's sign - positive  



Sensory system - 

all sensations  pain, touch, temperature, position, vibration sense are      well appreciated .

Cerebellar signs:

Heel knee incoordination : no

Finger nose incordination: no

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses


PALPATION:

•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.

•No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders are percussed.

 AUSCULTATION:

•S1 and S2 heard , no added thrills and murmurs heard.

 RESPIRATORY SYSTEM

 INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated 

 Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

 PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated 

 PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular- resonant

Infraclavicular- resonant

Mammary-resonant

Axillary-resonant

Infraaxillary-resonant

Suprascapular-resonant

Infrascapular-resonant

 interscapular- Resonant

 AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard.


ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving with respiration.

No dilated veins, hernial orifices , sinuses.

No visible pulsations

PALPATION:


Soft, non tender

Spleen liver kidney not palpable

PERCUSSION:


There is no fluid thrill , shifting dullness

AUSCULTATION:


 Bowel sounds are heard

 

Provisional diagnosis:-


Dengue fever with viral meningo encephalitis  under evaluation and  detected denovo diabetes mellitus type 2.

Investigations:


GRBS - 91 mg/dl

Fasting blood sugar- 168 mg/ dl
Hb1 AC -6.9

CUE:

Albumin +
Sugar - nil 
Pus cells - 6 - 8
Epithelial cells- 3-4
RBC - nil
Casts - nil 

CSF :

Sugar - 81
Protein-12.6
Chloride-113






 
















On day 10th /6:-
 
Vitals:-

Temperature: 99°F
Pulse rate: 76bpm
Resp rate:15cpm
BP:130/90mmhg
Spo2:96%

GRBS- 197mg/dl


On day 11th/6:-

Vitals:- 
Temperature: 99°F
Pulse rate: 78bpm
Resp rate:16cpm
BP:120/90mmhg
Spo2:96%

GRBS- 190mg/dl 

On 12th /6-

Vitals:-
Temperature: Afebrile 
Pulse rate: 76bpm
Resp rate:16cpm
BP:130/90mmhg
Spo2:96%

GRBS- 168mg/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

◇Inj.pan 40 mg iv /od

◇Tab. Naproxen 250 mg po/tid.

◇Flexbenz gel for L/A on thighs






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