70 F with involuntary movement and fever .
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The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever .
70 year old female,resident of miryalaguda came with
Chief complaints:
History of fever since 4 days
Involuntary movements on since 2day
History of presenting illness:
Patient was asymptomatic 5 days ago when she developed HIGH GRADE FEVER which was gradual in onset ,associated with chills and rigors .
associated with Vomiting which was non projectile,non bilious ,non blood stained with contents as undigested food associated with mild abdominal pain,which subsided on an episode of vomiting .
In view her condition she was taken to her nearest local RMP where she was administered I.v fluids and was diagnosed with DENGUE and low platelet counts Platelet count was 30K - 37K - 40K and was treated for the same .
Patient then developed involuntary movements on upper limbs and lower limbs which were abrupt in nature and in association with altered sensorium .
Patient had no history of headache
Trauma recent operation
blurring of vision,
giddiness
Dyspnea
,exposure to toxins,
intoxication,
recent change in her medication (thiazides)
No h/o uprolling of eye balls
Patient's daily routine:
*Wakes up at 7:00 am
Does her daily chores and prepares her breakfast and has her first meal of the day by 8:00am .(mostly consumes dal and rice for breakfast ).
Watches television
*Around 2:00pm
Has second meal of the day
*In the afternoon
Sleeps for few hours
Wakes up from sleep prepares food
*At around 8:00 pm
Has her last meal of the day
*sleeps at 9:00 pm
(Patients daughter mentions that she is independent and an active women who prepares food for her self ,does all her daily chores without any need for help )
Past history:
No similar complaints in the past
No history of hypertension, diabetes, Tuberculosis, seizures
Marital history:
65 years old lady married at the age of 20 years , mother to three children born to her at ages
25 -1st child
28 -2nd child
30 -3rd child
( Miscarriage at the age of 27 )
All of them were normal vaginal delivery
Surgical history:
Underwent TUBECTOMY at age 34
1year back, underwent surgery for CATARACT
Family history:
No significant family history
Personal history:
Diet: Mixed (sample food -rice ,non veg occasionally )
Appetite: normal
Sleep: reduced since admission .
Bowel and bladder habits :normal
Addictions:patient is a chronic smoker (Chutta) since 30 years but stopped 1 year ago .
Occasionally used to consume toddy but stopped 20 years ago .
General examination:
Patient is conscious,coherent and Cooperative well oriented with time palce and person
No signs of pallor, Icterus cyanosis,Clubbing,Lymphadenopathy , pedal edema
Patient has diffuse swelling of right hand involving dorsum of her hand until the wrist joint cause due to I.V cannula insertion on admission to our hospital .
Vitals:
Temperature: 37 .7*C
Bp:110/80mmhg
Pulse rate 70bpm
Respiratory Rate :18 cpm
Saturation:96 % at room air
ON 5 th of December
E4 - eyes open spontaneously
V5 - oriented
M6 -obeys commands for movements
Total score -15
Head to toe examination:
Hair - normal
eyes-normal
ears-normal
no deviation of the mouth
Nails-no discoloration
Skin-patient has hyperpigemented circular areas which are confined to upper limb only .
chest: normal , no scars, sinuses , engorged veins
Abdomen:normal
spine: no deformity
Systemic examination:
CNS EXAMINATION
Higher mental functions:
On 4 th December On 5 th December
Speech :
Incomprehensible speech Comprehensive speech
Consciousness:
altered mental state Appears Lethargic
Behavior:
irritable Co operative
Cranial nerve examination
1st nerve: olfactory normal
2nd optic nerve
Visual acuity: counting fingers
3rd 4th 6th nerve: oculomotor ,trochlear,abducens
Primary gaze present
EOM RT LT
SR n normal
IR normal
SO normal
IO normal
Ptosis absent
Pupils reactive to light
5th nerve RT LT
Corneal reflex + +
Jaw jerk + +
Sensation over the face-present
7thh nerve;
Frowning absent
Orbicularis oculi
Nasolabial fold present
8th nerve
Vestibular cochlear
Rt left
Rinnies + +
Webbers + +
9th nerve
Uvula central
10th nerve
Gag reflex present
Hypoglossal nerve
Symmetrical tongue
Motor system
Muscle bulk -normal
Muscle tone -normal
Palpation
Power:
Grade 3 against gravity
Coordination movements normal
Finger nose test
Finger finger nose test
4th December On 5 th December
Involuntary movements present Absent
Reflexes: Rt left
Corneal + +
Conjuctival + +
Palatial + +
Abdominal + +
Plantar + +
Deep Reflexes
Jaw jerk + +
Biceps reflex + +
https://youtube.com/shorts/yO1dKBo_woM?feature=share
Supinator reflex + +
Triceps reflex. + +
https://youtube.com/shorts/fEdzWvIo7Fo?feature=share
Knee jerk Could not ellicite
Ankle jerk
Sensory examination:
Fine touch crude touch present
responding to pain
Temperature felt
Vibration felt
meningeal signs
On 4 th December On 5 th December
Kerning sign positive Present
Brudzinikies sign
Neck stiffness
CVS
On palpation
Apex beat was felt in the 5 th inter coastal space medial to the mid clavicular line
Jvp was normal
No precordial bulge
No parasternal heave
-S1,S2 heard no murmurs
RS-
On inspection
Chest is b/l symmetrical
Expansion of chest equal on both sides
Position of trachea -central
No visible scars sinuses
On palpation
Expansion of chest was equal on both sides
Position of trachea -central
Tactile vocal fremitus -was felt
On percussion
all lung areas resonant
On auscultation
BAE + ,wheeze present
Vocal resonance - all areas resonant
PER ABDOMEN -soft ,tender on palpation and no organomegaly
Umbilicus -Inverted
bowel sounds - heard
Altered sensorium secondary to hyponatremia?, viral dengue?( ns1+) meningo encephalitis?
Treatment:
Discussion:
Use of dexamethasone in meningitis:
meta-analysis of randomized controlled trials performed since 1988 showed a beneficial effect of adjunctive dexamethasone therapy in terms of severe hearing loss in children with Haemophilus influenzae type b meningitis and suggested a protective effect in those with pneumococcal meningitis if the drug was given before or with parenteral antibiotics.
Patients were randomly assigned to receive *dexamethasone* sodium phosphate (Oradexon), at a dose of 10 mg given every six hours intravenously for four days, or *placebo* that was identical in appearance to the active drug.
The study medication was given 15 to 20 minutes before the parenteral administration of antibiotics. After the interim analysis, the protocol was amended to allow administration of the study medication with the antibiotics.
Patients were initially treated with amoxicillin (2 g given intravenously every four hours) for 7 to 10 days, depending on the cause of the meningitis and the clinical response.
The primary outcome measure was the score on the Glasgow Outcome Scale eight weeks after randomization, as assessed by the patient's physician.
Reference:
https://www.nejm.org/doi/full/10.1056/nejmoa021334
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