48 yr old male with fever ,paraperisis and altered sensorium

 A 48yr old male patient ,resident  of chityala came to the opd with cheif complaints   C/C  of

Fever since 10 days

Altered sensorium  since 5 days

Weakness of bilateral lower limbs - 3days 

H/o of oliguria - 3days

HOPI

Patient was apparently  asymptomatic 1yr back then he developed decreased urine output for which they admitted in hospital and foleys was placed , then he was diagnosed with prostatomegaly with Rt renal calculi.

 since 10 days patient have high grade fever on and off  not associated with vomitigs/loose stools/cough

Altered sensorium since 5days

Since 3 days patient had bilateral lowerlimb  weakness ,difficulty to move  B/L lower limbs associated with decreased urine output since 3 days. 

PAST H/O

 No H/o of hypertension , diabetes , asthma, TB , epilepsy .

H/o HIV  10 YRS back

PERSONAL H/O

Diet - mixed

Appetite  - normal

Bowel ,bladder movement- regular

Sleep - adequate

Regular smoker , alcoholic(occasionally 250ml)

FAMILY H/O

no relevant family  h/o

GENERAL EXAMINATION 

patient is  conscious ,not coherent , not oriented to time place and person.

VITALS

Bp 130/90  temp 101°F    PR -102 bpm  spo2 - 98%



10-06-21

Vitals 
Bp 120/80  PR 100bpm


12-06-21
Vitals temp 101.7 °F PR 105bpm





pallor - absent

Icterus - absent 

Cyanosis - absent

Kiolonychia - absent 

Lymphadenopathy  - absent 

Clubbing  - absent 

Oedema - absent 

SYSTEMIC EXAMINATION 

CVS 

S1 s2 heard , no murmurs , no thrills

RESP

Bilateral  air entry  with normal vesicular breath sounds heard , no wheeze , no dyspnea , trachea is central.

ABDOMEN 

Shape of abd - obese

No tenderness , Palpable mass ,tenderness, freefluid , bruit.

liver and spleen - not Palpable 

Bowel sounds - present 










CNS

 incoherent 

Neck stiffness  , kernings sign +ve

Sensory -  cannot be examined

Motor -

                     R            L

Tone    UL   N            N (normal)    

             LL  decreased    decreased 

Power  UL   5/5            5/5

              L/L  1/5            1/5

REFLEXES

RT SIDED

biceps 2+ , triceps 2+ ,supinator 2+,knee absent, ankle absent 

LT SIDED 

biceps 1+, triceps 2 + , supinator 2+ , knee absent  ankle absent

No cerebellar signs 

PROVISIONAL DIAGNOSIS 

altered sensorium secondary to meningoencephalitis  ( infarct in splenium of corpus collosum )

INVESTIGATIONS 

RBS , RFT, MRI ,CXRAY , CSF analysis


              CSF 10-06-21














TREATMENT 

1 .inj PAN 40mg IV /OD
2 . IV NS/RL  75 ml/hr
3 .inj thiamine  1 amp in 100ml NS IV / BD
4. Inj optineuron 1 amp in 100ml NS IV /OD
5 . Bp /PR/ Spo2 , temp monitoring  4th hourly
6. Tab ECOSPORIN Av 75/40mg  OD

 treatment  update  10-06-21

Inj PAN 40 mg /OD
IVF NS/RL 75 ml/hr
INJ THIAMINE 100ML NS TID
INJ OPTINEURON 10ML OD
TAB  CEFTRIAXONE 2gm /IV/BD
TAB ECOSPORIN -AV 75/40 mg /OD
GRBS charting 6th hourly

 update(10-06-21)

Patient condition is improved , oriented to time place and person
 By  history it is found that ,he is HIV positive since 10 + yrs
Csf analysis showed raised protein 2.9 gms and decreases glucose 28mg/dl
Csf sent to culture.
Patient is started on inj ceftriaxone .

Update (12 -06-21)
Patient is oriented to time ,place and person
Csf analysis shows 40 percent lymphocytes 
Csf culture shows diptheroids
TB is considered one of differential 
Anti tubercular therapy is yet to start
Vitals temp 101.7 PR 105




Update (17-06-21)




Treatment update 
Same treatment continued 
+
 
Started on ATT  -HRZE REGIMEN 4 TAPO/OD
Started on HRT -TLD REGIMEN 1TAB PO /OD



 













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