64/M ? Tb meningitis Aki

 64/M came to casuality with 

CHIEF COMPLAINTS :

Patient came to casuality with chief complaints of 
- unable to talk since 1 day 
- hiccups since 7 days
-  bowel and bladder incontinence, loss of appetite  since 3 days 
- loose stools 5 days back relieved on medication 
- fever 4 days back 

History of present illness :- 

Patient was apparently asymptomatic 7 days back , he then developed hiccups , loss of speech

-  5 days back he developed diarrhoea  5 episodes/ day , for one day which was relieved on medication 

-loss of appetite since 3 days , since one day he is unable to talk
 
- No H/O SOB , cough , palpitations
- No H/O loss of consciousness , giddiness , involuntary passage of urine and stools .

Past history :- 
- h/o panic attack one month back secondary to family issues 

- K/C/O DM2 since 2 yrs , on medication , 
-tab Metformin OD , tab Glimiperide OD

- Not a K/C/O HTN, TB, Asthma, epilepsy, CAD, CVD

Personal History :- 

Appetite - lost

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements - incontinence 

Addictions: Occasional alcoholic ( during functions ) , tobacco chewing occasionally 

Allergies : No allergies  

Family history :- not significant 

GENERAL EXAMINATION: 


Patient is conscious ,incoherent , uncooperative
 Moderately Built and Moderately Nourished .

Pallor : present 
Icterus : absent 
Cyanosis: absent 
Clubbing : absent 
Lymphadenopathy : absent 
Edema : absent
 





His vitals :- 

Temp: Afebrile 
BP : 100 / 50 mmHg 
PR : 120 bpm 
RR : 16 cpm 
SPO2 : 98 % at RA
GRBS : 193 mg/dl 
Qaa


SYSTEMIC EXAMINATION: 

CNS examination :-
State of consciousness : conscious 
Speech : incoherent 
Kernigs sign :- positive

Sensory system :- 

Pain - Normal 
Touch- fine touch - normal
      crude touch - normal
Temp - normal
Vibration - normal
Joint position - normal

Cranial nerves : intact


CNS :-
                    Right.                   Left
Tone :-   UL    hyper                 hyper 
               LL.   Hyper                hyper 

Power :- UL and LL     moving all four limbs in response to pain     
                     

Reflexes :-
Biceps           + +
Tricep s     + +
Supinator     + +
Knee      + +
Ankle. ++
Flexor. Plantar. Plantar 

Finger nose in coordination - no 
Heel knee in coordination - no

CVS : S1 S2 + ,no murmurs ,no thrills 

Respiratory System : decreased air entry on left side . Diffuse crepts on left side. Position of trachea - central.

Per abdominal examination:- 

Soft , non tender , no signs of hi organomegaly 

Investigations:- 
ECG 

Chest x ray pa view ;- 

USG abdomen:- 

MRI brain :- 




hemogram 
RBS
LFT

serum creatinine 

serum electrolytes :- 

provisional diagnosis:- 

CVA , hyponatremia 

Management:-
1) IVF 0.9 %NS IV @ 50 ml / hr 
2) Inj , 1 amp Optineuron in 500 ml NS IV /OD 
3) tab Ecosprin AV 75/10 RT / OD / HS
4) GRBS monitoring 6 th hrly 
5) Inj Thiamine 200 mg IV/BD in 100 ml NS 

  29/12/2022 :-

AMC 
Bed 4 
Day 2 

S : 
No fresh complaints 

O : 
Patient is conscious , non coherent, non cooperative
BP :110/60 mm hg 
PR :- 110 bpm
RR :  16 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
CVS : S1 , S2 heard, no murmurs  
RS : BAE + , decreased air entry on left side , no wheeze , no crepts

CNS :- 
Reflexes :-   right.                Left 
Biceps        -                          -
Triceps      -                            -
Supinator   -                            -
Knee          -.                           -
Ankle         -                            -

GCS : E4V1M4
                     Right.                      Left
Tone :- UL      hyper                    hyper 
             LL       hyper                   hyper 

Power :- UL  : moving all four limbs in                          LL :   response to pain 

P/A : soft , non tender  

A :- 
- Altered sensorium secondary to meningoencephalitis 
- hyponatremia 
- AIS ( Tiny acute infarct in right temporal lobe ) 

P :
) IVF 0.9 %NS IV @ 50 ml / hr 
2) Inj , 1 amp Optineuron in 500 ml NS IV /OD 
3) tab Ecosprin AV 75/10 RT / OD / HS
4) GRBS monitoring 6 th hrly 
5) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
6) T.Baclofen 10 mg RT/TID

Lumbar puncture video performed on 29/12/2022 at 12 pm




 


On 30/12/2022
ICU Bed 6
Day 2 

S: 
No fever spikes 
Stools passed 
 
O : 
Patient is drowsy but arousable 
BP :120/80 mm hg 
PR :- 102 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 275 mg/dl
I/O : 1500/900 ml 
CNS :- GCS : E3V4M6
CVS : S1 , S2 heard, no murmurs  
RS : BAE + , decreased air entry on left side ,   crepts +
P/A:- soft , non tender 

A :- 
- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left sided pneumonia ( ?TB ) 

P :
Patient was started on ATT 

1)  IVF 0.9 %NS IV @ 75 ml / hr 
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj , 1 amp Optineuron in 500 ml NS IV /OD 
4) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
5) Inj .Monocef 2 gm IV/BD 
7) Inj . Dexa 6 mg IV / TID 
9) ATT therapy PO/OD 
10) GRBS monitoring 6 th hrly
11) vitals monitoring 6 th hrly
12) Temp monitoring 4 th hrly
13) Inj H. Actrapid insulin SC TID acc to GRBS 




31/12/2022: 

Bed 6
Day 3 

S :
Pt in altered sensorium
 
O : 
Patient is drowsy but arousable 
BP :120/80 mm hg 
PR :- 102 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 246 mg/dl
I/O : 2100/1100 ml 
CNS :- GCS : E2V1M4
            Right.                      Left
Tone :- UL      hypo                   hypo
             LL       hypo                  hypo

Power :- UL  : moving all four limbs in                          LL :   response to pain 

CVS : S1 , S2 heard, no murmurs  
RS : BAE + , decreased air entry on left side ,   crepts +
P/A:- soft , non tender 

A :- 
- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left sided pneumonia ( ?TB ) 

P :

1)  IVF 0.9 %NS IV @ 75 ml / hr 
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
4) Inj . Dexa 6 mg IV / TID 
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS 
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 

1/1/2023 :- 

1) IVF 0.9 %NS IV @ 75 ml / hr 
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
4) Inj . Dexa 6 mg IV / TID 
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS 
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 

SOAP NOTES 
 2/1 /2023
ICU
Bed 6
Day 5  
Unit 3 

Dr.Nikitha (SR )
Dr.Vamshi Krishna ( PG 3 )
Dr. Nishitha ( PG 2 ) 
Dr.Govardhini Reddy ( PG 1 )
Dr. Meghana ( intern )
Dr. Tejarshini ( intern) 


S: 
Pt in altered sensorium  


O : 
Patient is stuporous 
BP :110/70 mm hg 
PR :- 107 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 146 mg/dl
I/O : 2100/1100 ml 

CNS :- GCS : E4V1M1
                        Right. Left
Tone :- UL hypo hypo
             LL hypo hypo

Power :- UL   : not moving even with pain LL : 
 Reflexes:-not elicited 
Brain stem reflexes :-
B/L corneal + ,conjuctival + , pupillary + , 
Doll's eye : absent on left 
Gag :+ 
Plantar : left - , right - increased  

CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  crepts +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 

- Left sided pneumonia ( ?TB ) 


P:-
) IVF 0.9 %NS IV @ 75 ml / hr 
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
4) Inj . Dexa 6 mg IV / TID 
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS 
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 

Investigations :-



CBNAAT OF CSF : NEGATIVE 

3/1/2023: 
ICU
Bed 6
Day 6 


S : no fresh complaints
O:Patient is stuporous 
BP :110/70 mm hg 
PR :- 102 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 146 mg/dl
I/O : 2100/1100 ml 

CNS :- GCS : E4V1M1
                        Right. Left
Tone :- UL hypo hypo
             LL hypo hypo

Power :- UL and LL   : not moving even with pain  
 Reflexes:-not elicited 
Brain stem reflexes :-
B/L corneal + ,conjuctival + , pupillary + , 
Doll's eye : absent on left 
Gag :+ 
Plantar : left  -  , right - increased  

CVS : S1 , S2 heard, no murmurs  
RS : BAE + , crepts +
P/A:- soft , non tender 

A :- 

- Altered sensorium secondary to meningoencephalitis (? TB ) 
- Left sided pneumonia ( ?TB ) 
- prerenal AKI
- bilateral fixed flexion deformity since 2 yrs 

P :-

1) IVF 0.9 %NS IV @ 100 ml / hr 
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
4) Inj . Dexa 6 mg IV / TID 
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS 
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd
hrly
11 ) physiotherapy was done 

4/1/2023 :
Bed 6
Day 7 
S :
Stools not passed since 3 days
O :Pt is C/C/C
BP :100/70 mm of Hg 
PR : 120 bpm
RR :18 / min
Temp : 98 F
Spo2 : 98 % at RA 
GRBS : 167 mg / dl
I/O : 2600/1050 

CNS :- GCS : E4V1M1
                  Right. Left
Tone :- UL hypo hypo
             LL hypo hypo

Power :- UL  and LL : not moving even with pain 
 Reflexes B/L:  biceps , triceps , supinator , ankle , knee :-not elicited 
Brain stem reflexes :-
B/L corneal + ,conjuctival + , pupillary + , 
Doll's eye : absent on left 
Gag :+
Plantar b/L : mute   
CVS : S1 , S2 heard, no murmurs  
RS : BAE + , expiratory fine crepts + in right and left infraaxillary areas 
P/A:- soft , non tender 

A :- 

- Altered sensorium secondary to meningoencephalitis (? TB ) 
- Left sided pneumonia ( ?TB ) 
- prerenal AKI
- bilateral fixed flexion deformity since 2 yrs 

P : 
1) IVF 0.9 % 2 units NS, 1 unit RL IV @ 100 ml / hr 
2) Nebulization with inpravent  - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS 
4) Inj . Dexa 6 mg IV / TID 
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS 
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd
hrly
11 )passive  physiotherapy 
12) syp .Lactulose 15 ml RT /BD 
13) inj .Lasix 40 mg IV/ stat



 5/1 /2023
ICU
Bed 6
Day  8


S: 
Stools passed in morning 

O : 
Patient is conscious , oriented to person , not oriented to place , time 

BP :110/70 mm hg 
PR :- 117 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 188 mg/dl
I/O : 3150/1400 ml 

CNS :- GCS : E4V4M1

                     Right. Left                       
Tone :- UL hypo hypo              
             LL hyper hyper            

Power :- right left 
       UL. 0/5 2/5
        LL. 0/5. 0/5
                       
Reflexes:- not elicited 
CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  crepts +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's 
- Prerenal AKI 
- B/L fixed flexion deformity since 2 yrs 



P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr 
- Nebulization with duolin - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg PO/OD 
- syp lactulose 15 ml RT / BD 
- Inj .Thiamine 200 mg IV/BD in 100 ml NS 
- Inj . Dexa 4 mg IV / TID 
- ATT therapy PO/OD FDC:3 tab/ day 
 - RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 
- vitals monitoring 6 th hrly
- passive physiotherapy




 6/1 /2023




S: 
No fresh complaints 

O : 
Patient is conscious , oriented to person , not oriented to place , time 
BP :110/70 mm hg 
PR :- 78 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 139 mg/dl
I/O : 2000/1450 ml 
In
CNS :- GCS : E4V4M6
                        Right.                      Left
Tone :- UL      Normal                normal
             LL       normal              normal 

Power :- right         left 
       UL.      0/5         4/5
        LL.      0/5.       0/5

Reflexes:- not elicited 
CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  NVBS +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left> right  sided  pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's 
- Prerenal AKI 
- B/L fixed flexion deformity since 2 yrs 



P:-
-  IVF 2 units NS , 1 unit RL IV @ 100 ml / hr 
- Nebulization with duolin - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg PO/OD 
- syp lactulose 15 ml RT / BD 
- Inj .Thiamine 200 mg IV/BD in 100 ml NS 
- Inj . Dexa 4 mg IV / TID 
- ATT therapy PO/OD FDC:3 tab/ day 
 - RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change

7/1/23 


S: 
No fresh complaints 
No bed sores
No fever spikes
Passed 2 stools
c/o hiccups

O : 
Patient is conscious , oriented to person and  place 
BP :120/80 mm hg 
PR :- 115 bpm
RR : 20 cpm 
Temp : 97.0 F 
Spo2 : 98 % at RA 
GRBS :- 86 mg/dl
I/O : 2100/1350 ml 

CNS :- GCS : E4V5M6-15/15

                   Left      Right.                                
Tone :- UL   N         Hypo      
             LL    N         Hypo     

Power :-    Left      Right
       UL.      3/5         0/5
        LL.      2/5        0/5

Reflexes:- not elicited 
CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  NVBS +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left> right  sided  pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's 
- Prerenal AKI (resolving)
- B/L fixed flexion deformity since 2 yrs 



P:-
-  IVF 2 units NS , 1 unit RL IV @ 100 ml / hr 
- Nebulization with ipravent - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg RT/OD 
- syp lactulose 15 ml RT / BD 
- Inj .Thiamine 100 mg IV/BD in 100 ml NS 
- ATT therapy RT/OD FDL : 3 tabs/ day 
 - RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change

Investigations: 
RFT and LFT :
chest XRay AP view 
Fever chart 



SOAP NOTES 
 8/1 /2023
ICU
Bed 6
Day  11
Unit 3 

 


S: 
No bed sores , no fever spikes , stools passed 

O : 
Patient is conscious , oriented to person , not oriented to place , time 
BP :110/70 mm hg 
PR :- 78 bpm
RR : 17 cpm 
Temp : 98 F 
Spo2 : 98 % at RA 
GRBS :- 82 mg/dl
I/O : 2500/1050 ml 

CNS :- GCS : E4V5M6
                        Right.                      Left
Tone :- UL      hypo               normal
             LL       hypo            normal 

Power :- right         left 
       UL.      0/5         3/5
        LL.      0/5.       2/5

Reflexes:- not elicited 
CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  NVBS +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left> right  sided  pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's 
- Prerenal AKI 
- B/L fixed flexion deformity since 2 yrs 



P:-
-  IVF 2 units NS , 1 unit RL IV @ 100 ml / hr 
- Nebulization with duolin - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg PO/OD 
- syp lactulose 15 ml RT / BD 
- Inj .Thiamine 200 mg IV/BD in 100 ml NS 
- Inj . Dexa 4 mg IV / TID 
- Tab .Talvopton 15 mg PO/OD
- ATT therapy PO/OD FDC:3 tab/ day 
 - RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change  

 9/1 /2023


S: 
No fresh complaints 
No bed sores
No fever spikes
Stools not passed
c/o hiccups

O : 
Patient is conscious , oriented to person and place 
BP :120/70 mm hg 
PR :- 100 bpm
RR : 20cpm 
Temp : 97.2 F 
Spo2 : 98 % at RA 
GRBS 84mg/dl
I/O : 2100/1350 ml 

CNS :- GCS : E4V5M6-15/15

                   Left Right.                                
Tone :- UL N Hypo      
             LL N Hypo     

Power :- Left Right
       UL. 3/5 0/5
        LL. 2/5 0/5

Reflexes:- not elicited 
CVS : S1 , S2 heard, no murmurs  
RS : BAE + ,  NVBS +
P/A:- soft , non tender 


A :- 

- Altered sensorium secondary to meningoencephalitis (? TB  ) 
- Left> right sided pneumonia ( ?TB ) , old right upper lobe pulmonary Koch's 
- Prerenal AKI (resolving)
- B/L fixed flexion deformity since 2 yrs 
- Hyponatremia ? SIADH



P:-
- IVF 2 units NS , 1 unit RL IV @ 100 ml / hr 
- Nebulization with ipravent - 8th hrly , budecort - 12 th hrly
- Tab . Banadon 40mg RT/OD 
- syp lactulose 15 ml RT / BD 
- Inj .Thiamine 100 mg IV/BD in 100 ml NS 
- ATT therapy RT/OD FDL : 3 tabs/ day 
     Tab Isoniazid 75mg
     Tab Rifampicin 150mg
     Tab pyrazinamide 400mg
     Tab ethambutol 275mg
 - RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd hrly 
- Tab Tolvaptan 30mg PO/OD 
- vitals monitoring 6 th hrly
- passive physiotherapy
- frequent position change



PATIENT ATTENDER WAS CONTACTED TRICE ON PHONE CALL BUT THEY DID NOT ANSWER, LATER IN JANUARY 2024 TRIED TO CONTACT HIM THROUGH ANOTHER NUMBER AND THEY SAID HE PASSED AWAY IN FEB 2023.
OUTCOME - MORTALITY

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57/M MDR TUBERCULOSIS

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  A 57 yr old male lorry driver resident of gopalayapalli came to opd with chief complaints of  generalised body swelling since 1 month  decreased urine output since one month chest pain since 4 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic one month back later he developed swelling of face followed by abdomen and limbs which is pitting type since one month.  He had decreased urine output since one month.Intially there was dribbling of urine later there was complete stoppage of urine. He had chest pain since 4 days which was sudden in onset, dragging type,radiating towards back,and aggravated at night. H/o low grade fever associated with chills intermittent since one month. H/o shortness of breath (grade 3) since 1 month  H/O cough associated with sputum since one month and not relieved on medication. It is not associated with chest pain and no diurnal variation. Sputum is blood tinged. He had 9 sessions of dialysis (on alternate days) from one month last sessio
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