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24

 Case History and Clinical Findings

43 YEAR OLD FEMALE PATIENT CAME WITH COMPLAINTS OF FEVER SINCE 1 WEEK, VOMITINGS AND LOOSE

STOOLS SINCE 4 DAYS

INVOLUNTARY MOVEMENTSOF BOTH UPPER LIMBS AND LOWER LIMBS SINCE 1 DASY

HOPI: PATIENT WAS APPARENTL ASYMPTOMATIC 1WEEK BACK, THEN SHE DEVELOPED

FEVER OF LOW GRADE INTERMITTENT, RELIEVED ON MEDICATION NOT ASSOCIATED WITH

CHILLS AND RIGOR, BURNING MICTURITION, COUGH AND COLD

PATIENT HAD VOMITINGS WHICH ARE BILIOUS, NON PROJECTILE, NON BLOOS TINGED,

FILLED WITH FOOD PARTICLES(2-3 TIMES PER DAY)     C/O LOOSE STOOLS LOW VOLUME, WATERY CONSISTENCY, NON MCOPURUENT, NON

BLOOD TINGED, NO H/O OUTSIDE FOOD CONSUMPTION

PATIENT HAD 3 EPISODES OF INVOLUNTARY MOVEMENTS 9RIGIDITY OF BOTH UPPER

LIMBS AD LOWER LIMBS) ASSOCIATED WITH UPROLLING OF EYES, INVOLUNTARY

MICTURITION, TONGUE BITE AND IS IN POST ICTAL CONFUSION/IRRITABLE SINCE THEN

PAST HISTORY: K/C/O HTN SINCE 3 MONTHS(ON IRREGULAR MEDICATION OF UNKNOWN

DRUGS)

NOT A K/C/O DM, ASTHMA, THYROID DISORDERS, CAD, CVA

CHOLECYSTECTOMY DONE 4 YEARS AGO

PERSONAL HISTORY:TAKES MIXED DIET, NORMAL APPETITE, BOWEL AND BLADDER

HABITS ARE REGULAR

ADDICTIONS: OCCASIONALLY TODDY DRINKER

MENSTRUAL HISTORY: 3/30 DAYS, REGULAR

GENERAL EXAMINATION: PATIENT WAS IRRITABLE

NO SIGNSOF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

VITALS:

TEMP: 104F

BP: 130/90 MMHG

PR: 92 BP,

RR: 16 CPM

SPO2: 95% AT RA

GRBS: 211 MG/DL

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD, NO MURMURS

RESPIRATORY SYSTEM: BILATERAL AIR ENTRY PRESENT

PER ABDOMEN:OBESE, SOFT, NO TENDERNESS,

BOWEL SOUNDS HEARD

CNS: PATIENT WAS IRRITABLE

SPEECH- INCOHERENT

MENINGEAL SIGNS- ABSENT

COURSE IN HOSPITAL:

OPHTHALMOLOGYOPINION WAS TAKEN ON 2/3/23 I/V/O FUNDOSCOPIC CHANGES FOR

RAISED ICT: NO FEATURES OF RAISED ICT WERE SEEN IN BOTH EYES

ANESTHESIOLOGY REFERRAL WAS DONE ON 2/3/23 I/V/O SEDATION FOR MRI                         NEUROLOGY OPINION WAS TAKEN ON 2/3/2023 AND ADVISED INJ. VANCOMYSIN 1GM IV/BD

FOR 7 DAYS

INJ. DOXYCYCLINE 100 MG IV/BD X FOR 3 DAYS

INJ. ACYCLOVIR 1GM IV/TID FOR 5 DAYS

INJ. DEXA 8MG IV/BD FOR 7 DAYS

Investigation

HEMOGRAM ON 2/3/23: HB- 11.8 GM/DL, TLC- 12,500 CELLS/CUMM, PLT- 2.35 LAKHS,

SMEAR:NORMOCHROMIC NORMOCYTIC BLOOD PICTURE

HEMOGRAM ON 3/3/23; HB- 11.8 MG/DL, TLC- 9400 CELLS/CUMM, PLT- 2.05 LAKHS,

SMEAR:NORMOCHROMIC NORMOCYTIC BLOOD PICTURE

LDH- 331 IU/L

M.P STRIP TEST:NEGATIVE

BT- 2 MIN. 30SEC

CT- 4 MIN

C- REACTIVE PROTEIN: NEGATIVE

MRI BRAIN:

NO ABNORMALITY DETECTED IN BRAIN PARENCYMA

DILATED PERIOPTIC CSF SPACES AND EMPTY SELLA

2D ECHO: EF: 65%

TRIVIAL AR, NO MR/TR

NO RMWA. NO AS/MS

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION. NO PAH/PE

Diagnosis  

GTCS (3 EPISODES ) SECONDARY TO ACUTE ENCEPHALITIS (BACTERIAL>VIRAL)? CEREBRAL MALARIA ,H/O ACUTE GASTROENTERITIS(RESOLVED) WITH AKI SECONDARY TO ATN (NON OLIGURIC) (DRUG INDUCED -ACYCLOVIR , VANCOMYCIN)WITH HYPERTENSION SINCE 3 MONTHS 

Treatment Given(Enter only Generic Name)

IV FLUIDS AT 75ML/HR

INJ. VANCOMYSIN 1GM IV/BD FOR 7 DAYS

INJ. DEXA 8MG IV/BD FOR 7 DAYS

INJ. MONOCEF 2GM IV/BD FOR 7 DAYS

INJ. DOXYCYCLINE 100 MG IV/BD X FOR 3 DAYS

INJ. ACYCLOVIR 1GM IV/TID FOR 5 DAYS

INJ. FALCIGO 120 MG IV

INJ. PCM 1GM IV/TID FOR 2 DAYS

INJ. PAN 40 MG IV/OD

INJ. LEVIPIL 500 MG IV/BD FOR 4 DAYS             INJ. OPTINEURON 1 AMPIN 100ML NS

TAB. LEVIPIL 500MG PO/BD FOR 2 DAYS

TAB. ATENOLOL 50MG+ TAB. AMOLODIPINE 5 MG PO/OD

Advice at Discharge

TAB. LEVIPIL 500MG PO/BD

TAB. ATENOLOL 50MG+ TAB. AMOLODIPINE 5 MG PO/OD

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