1701006160 CASE PRESENTATION

 LONG  CASE :

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 

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SHORT  CASE :

A 15 year old male resident of west Bengal came to OPD with 

C/O : 

1. Chest pain since 3 months 
2. Shortness of breath since 1 month 

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 3 months back then he developed

1. chest pain which was insidious in onset, gradually progressive dull aching non radiating increased on lying down, and on turning towards left side. Pain relieved on sitting. First the parents thought it as acidity and gave medication for it and not relieved.
2. Pain was severe 3 months ago for which patient took medicines, the following month he didn't complain of severe pain. The pain aggravated last month for which they visited the doctor. After investigations they couldn't find any abnormality. 
3. No history of palpitations, PND, pedal edema, vomiting, hemoptysis, trauma.
4. Shortness of breath since 1 month, grade 2 (MMR). Insidious in onset, gradually progression, aggravated on lying down and on lying on left side. Relieved on sitting. Associated with dry cough
5. Not associated with wheeze and cold, fever, sore throat, headache.

PAST HISTORY : 

-No similar complaints in the past

-7yrs back patient had complaints of body pains for which he was managed conservatively

-4 yrs back patient had complaints of body pains for which he was managed conservatively at our hospital

- 2 yrs back he developed herpes on left side of face.

-No history of DM, HTN, TB, Asthma, epilepsy

PERSONAL HISTORY : 

Diet : mixed

Appetite : normal

Sleep : adequate

Bowel/Bladder  : regular

Addictions : nil 

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  : 17cpm 

Blood pressure  : 120/70 mm of Hg 

Temperature  : afebrile 

RESPIRATORY EXAMINATION : 

Inspection : 

-Shape of chest - elliptical 

-No tracheal deviation 

-Chest bilaterally symmetrical

-Expansion of chest-  equal on both sides

-Use of accessory muscles - not present 

-No dilated veins,pulsations,scars, sinuses.

Palpation : 

-No local rise of temperature and tenderness

-trachea- central

-Apex beat- 5th intercoastal space,medial to mid clavicular line.

-Vocal fremitus- decreased on left side in infra axillary region.

Measurements:

-Anteroposterior length : 13.5cm

-Transverse length : 27cm

-Circumference : 78cm

Percussion : 

-dull note heard at the left infra axillary area. 

Auscultation : 

-Bilateral air entry present. 

-Vesicular breath sounds heard. 

-Decreased intensity of breath sounds heard in left infra axillary area

-Vocal resonance: decreased in left infra axillary  area

CVS EXAMINATION : 

-S1and S2 heard, no murmurs 

ABDOMINAL EXAMINATION : 

-soft non tender 

-no organomegaly

CNS EXAMINATION : 

-Sensory and motor system normal

INVESTIGATIONS : 

PROVISIONAL DIAGNOSIS : 

-Left side hydropneumothorax 

 

TREATMENT : 

-Tab.paracetomol

-IV fluids