Acute Encephalitis with mild prostatomegaly.
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
Team:
Interns
M Supriya
Sowmya Kota
Mohitha
Amrutha
Sanjay
Dr Durga Krishna PGY1
Dr Ajith Kumar PGY2
Dr Laxma Reddy PGY3
Dr Manasa PGY3
Dr Vijayalaxmi (Ast prof.)
51 yr old male farmer presented with
C/o headache in occipital region from 2months
C/o Fever from 10 days
C/O general weakness from 5 days
C/o excessive sleeping during day time from 5 days
C/o difficulty in passing urine from yesterday
Patient was apparently asymptomatic 2 months back, later he developed headache in occipital region-2episodes with 1 month gap in 2months.Each episode was sudden in onset, aggravated with while doing work, no relieving factors.
H/O Fever from 10 days,insidious onset, associated with chills and rigors,continuous type, not subsided with medication.
On day 5 of his fever, he went to hospital where he got investigations done and was diagnosed with Typhoid and treated with iv antibiotics for 3 days.
He has generalised weakness from 3 days. He was taken to suryapet hospital where he was put on antibiotics from 2 days.
He was not responding to commands of family members from yesterday but was able to eat , take medication.
He was unable to pass urine but had the urge to pass urine.
PAST HISTORY:
Not a k/c/o HTN,DM,CVA,CAD,TB,asthma.
H/O COVID 19, 3 months back.
PERSONAL HISTORY:
Excessive sleep.
Normal appetite.
Mixed diet.
Decreased micturition.
Alcohol- occasionally.
No known drug allergies.
O/E:
Patient is conscious,coherent, not oriented to time and place , oriented to person at admission.
Vitals:
Bp-110/70mm hg
Temp afebrile
PR-80bpm
Spo2-99%at RA
SYSTEMIC EXAMINATION:
CVS-S1 S2 +
No murmers
RS- BLAE+
NVBS+
P/A- Soft, nontender,
no organomegaly.
CNS Examination :
HMF- oriented to person. Not oriented to time,place.
Tone- normal in all 4limbs
Power- Right Left
UL- 5/5 5/5
LL- 5/5 5/5
Superficial reflexes- intact.
DTR- Right Left
Biceps. +++ +++
Triceps +++ +++
Supinator - -
Knee +++ +++
Ankle ++ ++
Plantar Extension Extension
Sensory system - normal
Cranial nerves- intact.
Meningeal signs-
No neck rigidity.
No kernig’s sign.
No brudzinski’s sign.
Cerebellar examination- normal
UROLOGY OPINION
INVESTIGATIONS:
?ACUTE ENCEPHALITIS WITH MILD PROSTATOMEGALY WITH RIGHT RENAL CALCULI.
TREATMENT:
Inj Ceftriaxone 1gm IV BD
Inj Dexamethasone 8mg iv bd
Inj Pantop 40mg iv bd
IVF-NS @50ml per hr.
Syp Lactulose 15ml po/tid
Tab Tamsulosin 4mg po/HS
Daily charting:
Comments
Post a Comment