70/M ALTERED SENSORIUM SECONDARY TO TB MENINGITIS

 A 70 Years Old Man Who was a Farmer By Occupation Presented to Casualty With 

Altered Sensorium Since 3 Days 

Fever Since 20 Days 

HOPI : 

Patient Was Apparently Asymptomatic Till 2014 ;

2014 - Patient Had Fever Associated with Cough for which he went to Hospital & Was Diagnosed to Have ? Pneumonia with DENOVO DM2 & Was Prescribed with OHAs ( Tab.METFORMIN & Tab.GLIMIPRIDE )

6 Months Back - Patient Had Fever Associated with Cough for Which he Went to Hospital & Said to Have High Sugars along with Lung Infection ; Got Treated & Discharged in a Hemodynamically Stable Manner.Started using insulin for Diabetes Since Then 

20 Days Back : Patient Had Fever with Cough ; For Which He went to Hospital & Suspected to Have TB But Reports Turned out to be Negative & Patient Discharged as LAMA & When He Returned Home 3 Days Back He Gradually Developed Altered Sensorium & Couldn't Recognise His Attendants

Past History :

K/C/O DM2 Since 9 Years and on Regular Medications

N/K/C/O HTN ; TB ; EPILEPSY ; ASTHMA 

Addictions : 

He Started Consumption of Alcohol at the age of 20years & It became a habit to drink 90ml per Day Till 6 Months Back

He Started Smoking Beedis at the age of 20 Years & It Became a Habit to Smoke 20 Beedis Per Day 

On Presentation : 

BP - 110/80mmHg

PR - 110/min

Temp - 102.5 F

RR - 22/min 

Spo2 - 98% @RA

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E2V2M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone - Normal in Both UL & Hypertonia in Both lower limbs

Power - 4/5 In all 4 Limbs

Reflexes - B T S K A - 2+ 

Plantars - RT - Mute & Left - Flexor


Investigations -


ECG-



S. Urea-24mg/dl

S creatine-0. 8mg/dl

S. Electrolytes -

Na+-132

K+- 3.6

Cl- 98

Ca2+ 1.20

LFT-



Hemogram-



Rbs-157mg/dl

HbA1c-6. 8%

ABG-


Chest XRay-



CSF analysis-

glucose -42

Protein -60

Cl-121

ADA-131

CSF CELL COUNT

Vol-0. 5 ml

Color- colorless

Appearance- clear

Total count-104 cells

DC-

60% lymphocytes

20% monocytes

20% neutrophils 

Others- nil

RBC- nil


Provisional diagnosis -

?TB meningitis


Treatment -

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @50 ml/hr

Inj. Ceftriaxone 2 GM iv stat

Then inj . Ceftriaxone 1 GM iv bd

Inj Dexa 6 mg iv stat then 

Inj. Dexa 6mg iv tid

Monitor vitals 2 nd hourly

Grbs monitoring

Strict input and output charting

Inj. Neomol 1 GM iv /sos ( if temp>101F)









16/02/23

ICU-BED NO. 3

UNIT-2

DOA-15/2/23

70 year old man c/o fever since 20 days and altered sensorium since 3 days


S-

No fever spikes

Patient obeying to commands


O-

BP - 120/70mmHg


PR - 98/min


Temp - 98F


RR - 22/min 


Spo2 - 98% @RA


Grbs-250 mg/dl


CVS - S1S2 Heard & No Murmurs 


RS - BAE + ; NVBS + 


P/A - Soft & Non Tender


CNS - 


GCS - E2V2M5


RT Pupil - Couldn't be assessed


Lt Pupil - NSRL



A-

Altered sensorium under evaluation secondary to? meningitis 

?TB meningitis


Investigations -

Hb- 12.0g/dl

TLC- 8700

PLC- 3.02LAKHS

Lymphocytes -32

Pcv-35. 2


S Urea-24mg/dl


S creatine-0. 8mg/dl


S. Electrolytes -


Na+-132


K+- 3.6


Cl- 98


Ca2+ 1.20


LFT-

Total bilirubin-0. 9

ALP-144

Total proteins-6. 2

Albumin-3. 0


Rbs-157mg/dl

HbA1c- 6.8%


P-

Ryles tube feeds-200 ml milk every 4 th hourly


100 ml water every hourly


Iv fluids NS @50 ml/hr


Inj. Ceftriaxone 2 GM iv stat


Then inj . Ceftriaxone 1 GM iv bd


Inj Dexa 6 mg iv stat then 


Inj. Dexa 6mg iv tid


Monitor vitals 2 nd hourly


Grbs monitoring


Strict input and output charting


Inj. Neomol 1 GM iv /sos ( if temp>101F)


Inj. HAI S/C according to grbs





17/02/23

ICU-BED NO. 3

UNIT-2

DOA-15/2/23


70 year old man c/o fever since 20 days and altered sensorium since 3 days


S-

No fever spikes

Patient obeying to commands

Hiccups since yesterday afternoon 


O-

BP - 110/70mmHg

PR - 66/min

Temp - 95.5F

RR - 22/min 

Spo2 - 98% @RA

Grbs-

15/2/23

8am-250mg/dl

2pm-269mg/dl

4pm-272mg/dl

8pm-278mg/dl


16/2/23

2am - 200 mg/dl

8am - 250mg /dl

2pm 265mg/dl

8pm 140mg/dl

10pm 191 mg/dl


17/2/23

2am 197 mg/dl

8am 175mg/dl


Input-2300ml

Out put-1000ml

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E3V3M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone- normal in all 4 limbs 

Power- 4/5 in all 4 limbs 


A-

Altered sensorium(resolving) secondary to meningoencephalitis secondary to tuberculosis

K/c/o DM since 9 years


Investigations -

Hb- 11.5g/dl

TLC- 11000

PLC- 3.08LAKHS

Neutrophils -85

Lymphocytes -09

Pcv 34.6

RBC count 3.08


15/2/23

S.Electrolytes -

Na-135

K-4. 3

Cl-102

Ca2+1. 12


P-

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @100 ml/hr

Inj. Dexa 6mg iv tid day 3

Inj human actrapid s/c according to GRBS 

Tab. Isoniazid 275 mg (4tabs po/od) morning

Tab. Rifampicin 550 mg (4tabs po/od morning

Tab. Pyrazinamide 1550mg (4tabs po od morning

Tab ethambutol 825 mg po od morning

Grbs 7 th hourly

Inj. neomol 1 g iv sos( if temp >101F)

Strict input output charting 

Grbs monitoring

Tab benadone 40mg po/od

Tab baclofen 10mg po/sos

Inj perinorm 10mg iv stat 

Inj pan 40mg iv/od

MRI images




20/02/23


ICU-BED NO. 3


UNIT-2


DOA-15/2/23



70 year old man c/o fever since 20 days and altered sensorium since 3 days



S-


Fever spike at 2 am 100. 4F


Hiccups subsided


O-


Patient is drowsy not oriented to place time and person responding to only deep pain stimulation



BP - 110/70mmHg


PR - 86/min


Temp - 98.6F


RR - 22/min 


Spo2 - 97 % @RA            


GRBS 119mg/dl


Input-3400ml


Out put-1900ml



CVS - S1S2 Heard & No Murmurs 


RS - BAE + ; NVBS + 


P/A - Soft & Non Tender


CNS - 


GCS - E2V1M4


RT Pupil - Couldn't be assessed


Lt Pupil - dilated , sluggishly reacting to light


Tone- normal on right side 


Decreased on left side


Dolls eye positive bilateral


Jaw jerk absent 



                Right.   Left



Biceps     2+.        2 +


Triceps.    2+.         1+


Supinator. 1+.       1+


Knee         2+.      1+


ankle      1+.       -


Plantars bilateral flexors



Power-  right.      Left


UL.           3/5.         0/5



LL.             3/5.         2/5




INVESTIGATIONS -



Hb-12. 1g/dl


B urea -41 mg/dl


S creat -0. 7 mg/dl



S electrolytes-


Na-136


K-3. 7


Cl-98


Ca2+1.21




19/02/23


Ph-7. 48


Pco2-31. 8


Po2-75. 7


Hco3-23. 9


Na-126


K-3. 6


Ca2-0. 92


Cl-99




20/2/23-


Ph-7. 42


Pco2-30. 4


Po2-78. 5


Hco3-19. 7


Na-124


K-2. 9


Ca2-0. 52


Cl-96



A-


Altered sensorium secondary to meningoencephalitis secondary to tuberculosis


K/c/o DM since 9 years


With ? Old pulmonary kochs


Acute infarct in ? PCA? MCA territory


With new onset left hemiplegia



P-


Ryles tube feeds-200 ml milk every 4 th hourly


100 ml water every hourly


Iv fluids NS @100 ml/hr


Inj. Dexa 6mg iv tid day 5


Inj human actrapid s/c according to GRBS 


Inj. neomol 1 g iv sos( if temp >101F)


Inj pan 40mg iv/od


Tab baclofen 10mg po/sos


Tab. Isoniazid 275 mg (4tabs po/od) morning


Tab. Rifampicin 550 mg (4tabs po/od morning


Tab. Pyrazinamide 1550mg (4tabs po od morning


Tab ethambutol 825 mg po od morning


Tab. Pyridoxine 40 mg RT/OD 


Tab. Ecospirin 150 mg RT/OD


Tab. Clopidogrel 75mg RT/OD


Tab. Atorvastatin 20 mgRT/OD HS


Frequent changes in position 


Grbs 7 point profile 


Strict input output charting 


Grbs monitoring


21/02/23


ICU-BED NO. 3


UNIT-2


DOA-15/2/23




70 year old man c/o fever since 20 days and altered sensorium since 3 days




S-


2 fever spikes one at

 9pm yesterday night 101F

7am 101.4F

Stools not passed 

Hiccups subsided




O-


Patient is drowsy ,not arousable, not oriented to place time and person 

Febrile on touch 


BP - 120/80mmHg


PR - 82/min


Temp - 101.2F


RR - 24/min 


Spo2 - 95% @RA


            


GRBS 164mg/dl




Input-2400ml


Out put-2000ml




CVS - S1S2 Heard & No Murmurs 


RS - BAE + ; NVBS + 


P/A - Soft & Non Tender


CNS - 


GCS - E1V1M5


RT Pupil - Couldn't be assessed


Lt Pupil - normal in size not  reacting to light


Tone- normal on right side 


Decreased on left side


Dolls eye positive bilateral


Jaw jerk absent 



                Right.   Left 


Biceps     2+.        2 +


Triceps.    2+.         1+


Supinator. 1+.       -


Knee         1+.      -


ankle      -.        -


Plantars bilateral flexors


Power-  right.      Left


UL.           3/5.         0/5


LL.             2/5.         1/5




INVESTIGATIONS -


Hb-14.6g/dl

TLC 9300

Neu 71

Lymp 21

Plc 3.17

Pcv 40.8


B urea-29 mg/dl


S creat-0. 6 mg/dl


S electrolytes-


Na-136


K-3. 9


Cl-99


Ca2+1.09

Lft 

Tb 1.45

Db 0.21

Alp 247

Total protein 5.5

Albumin 2.44



19/02/23

Ph-7. 48

Pco2-31. 8

Po2-75. 7

Hco3-23. 9

Na-126

K-3. 6

Ca2-0. 92

Cl-99


20/2/23-

Ph-7. 42

Pco2-30. 4

Po2-78. 5

Hco3-19. 7

Na-124

K-2. 9

Ca2-0. 52

Cl-96



A-


Altered sensorium secondary to meningoencephalitis secondary to tuberculosis (on ATT since 15/2/23) with ?old pulmonary kochs with acute infarct in right thalamus and striati capsular region ,left midbrain, cerebellar hemisphere 


K/c/o DM since 9 years

With left hemiplegia (new onset)


With ? Old pulmonary kochs


Acute infarct in ? PCA? MCA territory


With new onset left hemiplegia




P-


Ryles tube feeds-200 ml milk every 4 th hourly


100 ml water every hourly


Iv fluids NS @100 ml/hr


Inj. Dexa 6mg iv tid day 7


Inj HAI s/c according to GRBS 


Inj. neomol 1 g iv sos( if temp >101F)


Inj pan 40mg iv/od


Tab baclofen 10mg po/sos


Tab. Isoniazid 275 mg (4tabs po/od) morning


Tab. Rifampicin 550 mg (4tabs po/od morning


Tab. Pyrazinamide 1550mg (4tabs po od morning


Tab ethambutol 825 mg po od morning


Tab. Pyridoxine 40 mg RT/OD 


Tab. Ecospirin 150 mg RT/OD


Tab. Clopidogrel 75mg RT/OD


Tab. Atorvastatin 20 mgRT/OD HS


Tab. Baclofen 10 mg RT/OD sos


Frequent changes in position 


Grbs 7 th hourly


Left upper limb and lower limb and chest physiotherapy twice daily


Sir bed and position change 2nd hourly


Eyecare 


Oral suctioning 4th hourly


Strict input output charting 


Grbs monitoring


22/02/23


ICU-BED NO. 3


UNIT-2


DOA-15/2/23


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