55 year old female with fever, headache,neck stiffness
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x ray chest:
A 55 YEAR OLD FEMALE WITH FEVER,NECK STIFFNESS AND HEADACHE
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Hall ticket number:1701006196
Final practical examination long case
Chief complaints :
A 55 year old female who is house maid by occupation came with chief complaints of
- Headache since 20 days
- Fever since 5 days
- Neck stifness since 5 days
History of presenting illness:
Patient was apparently asymptomatic 20 days back then she developed
Headache which was insidious in onset gradually progressive and relieved on medication.Headache was aggravated 5 days back inspite of taking medications. No aggravating and relieving factors
Fever: Insidious onset since 5 days, intermittent fever,not relieved on medications.Fever is not associated with chills and rigors
History of neck stiffness since 5 days
History of one episode of vomiting 3 days back which is non projectile non billious,non blood stained and content is food particles
Patient had no history of cough,dyspnea,burning micturition, loose stools
Past history:
No history of similar complaints in the past
7 yrs back she had history of CVA where both upper and lower limbs are paralysed and took some medication.
she took allopathy medicine for 6 months and she got recovered.
Denovo detected diabetes
Not a known case of hypertension,asthma, epilepsy, tuberculosis,thyroid
Surgical history: hysterectomy done at 25 years back
Family history:
No similar complaints in the family
Personal history
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder-regular bladder, constipation is present
No addictions
No allergies
General examination:
patient is examined in a well lit room,with informed consent
Patient is conscious, coherent, coperative. Moderately built moderately nourished.
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals:
Temperature: afebrile
Pulse rate: 78bpm
Resp rate:16cpm
BP:130/80mmhg
Spo2:96%
Systemic examination:
Central nervous system:
Higher mental functions
• conscious
• oriented to person and place ,time.
• memory - able to recognize their family members
• Speech - normal
Cranial nerve examination
• 1 - sense of smell present
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present on both sides
• 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present.
• 8- able to hear
• 9,10- uvula centrally placed not deviated
• 11- trapezius and sternocleidomastoid contraction present
• 12- no tongue deviation
Motor system
Tone -. Upper limbs. Lower limbs
Inspection - Normal Normal
Palpation -. Normal Normal
Bulk : right Left
Arm 28cm. 27cm
Forearm 20cm 18 cm
Thigh 33 cm 32cm
Calf 25 cm 23 cm
Power :
Muscles of neck -
• stenocleidomastoid- good
•Nuchal muscles- stiffness present
Slight tenderness present over the neck on examination.
Right Left
Biceps- 5/5 5/5
Triceps-. 5/5 5/5
Brachioradialis-. 5/5 5/5
Tibialis posterior-. 5/5 5/5
Reflexes: right. left
Biceps- + +
Triceps- + +
Supinator- +. +
Knee- + +
Ankle-. +. +
Meningeal signs -
Neck stiffness- present .
Kernig's sign - positive
Brudzinki sign - positive
Sensory examination-Normal
CARDIOVASCULAR SYSTEM:
S1 S2 Heart sounds – normal
No thrills/murmurs
RESPIRATORY SYSTEM:
Bilateral air entry present
Normal vesicular breath sounds heard,
No abnormal/added sound
ABDOMEN:
Abdomen is soft, non tender,No organomegaly, No ascites.
Investigations
Hemogram
Hb - 13 g/dl
TLC - 3500
N/L/E/M-60/30/2/8
PLT- 2.1 lakh per mm3
NC/NC
Fasting blood sugar- 168 mg/ dl
Hb1 AC -6.9
Urea- 38
Serum creatinine- 1.0
Uric acid - 4.9
Sodium- 141meq
Pottasium- 4.0
chloride- 10.5
Dengue NS1 antigen:
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
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
MRI:
2D ECHO
CSF ANALYSIS:
Sugar : 81
Protein : 12.6
X ray neck:
PROVISIONAL DIAGNOSIS:
Dengue fever with meningoencephalitis
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
