Clinical 07 03-2011

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Clinical 07 03-2011

  1. 1. STUDENT CPC 07/03/11<br />
  2. 2. PATIENT DETAILS<br />Name: VK<br />Age/Sex: 50y/male<br />CR No:566023<br />Adm.No:52869<br />DOA:12/07/10<br />DOD:20/07/10<br />EMOPD<br />
  3. 3. Presenting complaints<br />Fever – 5 days<br />Headache- 5 days<br />Seizures- 1 day<br />Altered sensorium - 1 day<br />
  4. 4. History of presenting illness<br />Fever- 5 days<br /> high grade, intermittent , not associated with chills and rigors, no diurnal variation, no aggravating and relieving factors.<br />Headache-5 days<br /> sudden onset, holocranial, not associated with vomiting.<br />
  5. 5. Cont…..<br />Seizures- 1 day <br /> GTCS type, 4 episodes, each lasting for 15 sec, associated with frothing from mouth, no bladder/bowel incontinence.<br />Altered sensorium - 1 day<br />
  6. 6. Cont….<br /><ul><li>No h/o cranial nerve deficits
  7. 7. No h/o bleeding manifestations
  8. 8. No h/o focal neurological deficits
  9. 9. No h/o rash
  10. 10. No h/o trauma
  11. 11. No h/o ear discharge
  12. 12. No h/o bladder/bowel disturbances.</li></li></ul><li>Past history:<br /> not known diabetic, hypertensive<br /> No other comorbid illnesses.<br />Family history- non significant<br />Personal history-<br /> Married, Mixed diet<br /> not known smoker/alcoholic<br /> no addictions<br />
  13. 13. Physical examination<br /><ul><li> Alert,E3V4M5
  14. 14. Vitals:</li></ul> PR- 86/min, regular<br />BP- 120/90 mm of Hg <br />Temp- 37° C<br />RR- 14/min<br /><ul><li>No pallor/clubbing/ icterus/cyanosis/pedal edema/lymphadenopathy/jvp(NR)</li></li></ul><li> Systemic examination<br />Per abdomen: Soft, non tender<br /> No hepatosplenomegaly<br /> FF(-),BS(+)<br />Cardiovascular system: S1,s2 (+)<br /> No murmurs<br />Respiratory system: <br /> bilateral air entry(+)<br /> normal vesicular breath sounds(+)<br /> no added sounds <br />
  15. 15. CNS Examination<br /><ul><li>B/l pupils 2mm size, equally reacting to light</li></ul>Fundus examination-normal<br /><ul><li>Meningeal signs – Neck rigidity(+)
  16. 16. Extraocular movements normal, No nystagmus
  17. 17. No facial asymmetry
  18. 18. Motor system: Tone normal in all four limbs</li></ul> Power 5/5 in all four limbs<br /> DTR- B T S K A P<br />Rt 1+ 1+ 1+ 1+ 1+ f<br /> Lt 1+ 1+ 1+ 1+ 1+ f<br /><ul><li>Sensory system- with in normal limits
  19. 19. Cerebellar system-with in normal limits</li></li></ul><li>hemogram:<br />
  20. 20. BIOCHEMISTRY:<br />
  21. 21. COAGULOGRAM<br />
  22. 22. csf analysis:<br />TC- No WBC seen<br />Protein-198mg,Sugar-28mg (CBS-106 mg)<br /> CSF glucose/ serum glucose- 0.26<br />Gram stain- negative, C/S- Sterile<br />Indian ink stain-negative<br />
  23. 23. RADIOLOGY<br />CECT brain- Normal study<br />NCCT head-- Normal study<br />CEMRI Brain – Normal study (films not available)<br />
  24. 24. Course and management<br />
  25. 25. CONT….<br />
  26. 26. Cont….<br />
  27. 27.
  28. 28.
  29. 29. DATABASE<br /><ul><li>55y old male , farmer, married, non alcoholic, no previous co morbid illness
  30. 30. Presented with symptoms of fever, headache, seizures and altered sensorium.
  31. 31. Investigations revealed—
  32. 32. High total leucocyte count, hyponatremia
  33. 33. CSF analysis- No WBC, High protein, low sugar, Gram stain & culture- sterile ,Indian ink stain-negative</li></ul>CEMRI Brain- normal study<br />CECT Brain- normal study<br />
  34. 34. <ul><li>possibilities
  35. 35. Febrile encephalopathy with no Focal deficit and fulminant course</li></ul>A. Primary CNS involvement- Meningoencephalitis<br /><ul><li>1. Pyogenic
  36. 36. 2. Viral
  37. 37. 3.Amebic meningoencephalitis</li></ul>B. Secondary CNS involvement<br /><ul><li> Septic encephalopathy</li></li></ul><li>Acute bacterial meningitis<br />FOR<br /><ul><li>h/o fever, headache
  38. 38. h/o Altered sensorium
  39. 39. Neck rigidity (+)
  40. 40. CSF showing high protein and low sugar</li></ul>AGAINST<br /><ul><li>h/o seizures
  41. 41. CSF showing no wbc, gram stain and culture - sterile
  42. 42. CECT brain- normal study
  43. 43. MRI brain- normal study
  44. 44. MOST LIKELY </li></li></ul><li>In a prospective observational study conducted in our institute among 127 patients who presented to emergency services with fever(duration<2 wks) & altered mentation over 1 year <br />Results:<br />BhallaA et al. J emergencies,trauma and shock 2010<br />
  45. 45. <ul><li>Seizures have been described in 15 to 30 percent of patients with bacterial meningitis and focal neurologic deficits in 10 to 35 percent of patients.</li></ul>Durand, et al. Acute bacterial meningitis in adults. N Engl J Med 1993; 328:21<br /><ul><li>An observational study found that bacterial meningitis was highly probable (≥99 percent certainty) when any one of the following parameters was present: a CSF glucose concentration below 34 mg/dL (1.9 mmol/L), a protein concentration above 220 mg/dL, a white blood cell count above 2000/microL, or a neutrophil count more than 1180/microL. CSF glucose concentrations less than 18 mg/dL (1.0 mmol/L) are strongly predictive of bacterial meningitis </li></ul> Spanos et al.. JAMA 1989; 262:2700. <br />
  46. 46. Normal or marginally ↑CSF WBC -> 5 to 10 % and are associated with an adverse outcome<br />New Engl J Med 2006;354:44-53<br /><ul><li>CSF bacterial cultures are positive in >80% of patients, and CSF Gram's stain demonstrates organisms in >60%.</li></ul>Harrison principles of internal medicine,17th edition<br />
  47. 47. In a prospective study involving 301 adults with suspected meningitis confirmed that clinical features can be used to identify patients who are unlikely to have abnormal findings on cranial CT (41 percent of the patients in this study), 235 patients who underwent cranial CT, in only 5 patients (2 percent) was bacterial meningitis confirmed <br />Hasbun R et. N Engl J Med2001;345:1727-33<br />
  48. 48. VIRAL MENINGOENCEPHALITIS-CAUSES<br />
  49. 49. Acute viral meningoencephalitis<br /> FOR<br /><ul><li>h/o headache, fever
  50. 50. h/o Altered sensorium
  51. 51. h/o seizures</li></ul> AGAINST<br /><ul><li>No focal neurological deficits
  52. 52. CSF –No WBC, low sugar
  53. 53. MRI-normal study</li></li></ul><li>Cont…<br />CSF shows low glucose in following viral causes of meningoencephalitis: mumps, LCMV, advanced HSV meningoencephalitis, Varicella zoster virus,<br /> Echo virus , Enterovirus<br />
  54. 54. Primary amebic meningoencephalitis<br /> FOR<br /><ul><li>h/o fever, headache
  55. 55. h/o seizures
  56. 56. h/o neck rigidity
  57. 57. CSF showing negative g/s & culture</li></ul> AGAINST<br /><ul><li>No h/o swimming in fresh water lakes.
  58. 58. No h/o focal deficits
  59. 59. CSF glucose- < 40 mg
  60. 60. MRI brain- normal study</li></li></ul><li>Sepsis associated encephalopathy<br /> FOR<br /><ul><li>h/o Fever, Altered sensorium
  61. 61. CT brain-normal study
  62. 62. MRI brain-normal study</li></ul> LESS LIKELY<br /> AGAINST<br /><ul><li>Neck rigidity(+)
  63. 63. CSF- low sugar
  64. 64. Liver function tests& renal function tests-normal</li></li></ul><li>Final diagnosis<br />ACUTE PYOGENIC MENINGITIS<br />
  65. 65. Terminal event<br /><ul><li>Raised Intracranial pressure
  66. 66. Aspiration Pneumonitis</li></li></ul><li> thank u<br />

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