A 47 yr old male ,farmer by occupation came with fever , headache and altered sensorium

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

A 47 yr old male ,farmer by occupation came with 
c/o fever since 3days 
c/o headache since 3days and altered sensorium since 2-3hrs.

HOPI:
Patient was apparently asymptomatic 3days back later developed high grade fever with chills, intermittent relieved with medication which was associated with headache.
Complaints of alter sensorium since 2 to 3 hours not talking and not working this brought to casualty.
No urine output since today morning.
No history of  burning micturition,  vomiting, loose stools,  SOB,  cough ,chest pain, bleeding manifestations.

PAST HISTORY:
N/K/C/O DM ,HTN,BA,TB, CVA,CAD, epilepsy
ADDICTIONS:
Smokes ,montly once and was a occasional drinker but stopped 1 month back.

O/E : 
Patient is not oriented to time ,place and person
Clubbing +
No Pallor /Icterus /Cyanosis /Edema of feet  /Lymphadenopathy.

VITALS :  
Temp :  101  F 
PR : 90 bpm
BP : 140/80 mmhg 
RR : 18 
SPO2 : 98 % at RA 
GRBS-122 mg/dl

SYSTEMIC EXAMINATION : 
CARDIOVASCULAR SYSTEM :  S1 and S2 heard, no murmurs heard 
RESPIRATORY SYSTEM : Bilateral air entry present ,  clear 
PA : soft and non tender
CNS:E4V3M6, 
pupils B/L NSRL
power- moving all limbs
tone- not able to elicit
reflex- 
             B        T      S     K     A
     UL   ++       -       -     ++     -
     LL   ++       -       -     ++     -
platars - flexors
Neck stiffness -present 
Kernigs - present.

PROVISIONAL DIAGNOSES:- Meningitis(? bacterial/? tubercular)

MRI Impression- Few lacunar infarcts in medulla on left side.No f/o raised ICT on MRI
TREATMENT: 
IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 8 MG IV STAT
TAB DOLO 650 MG RT/SOS
BP,PR monitoring 4 th hourly

LP done today at 2 am - showing around 450 cells? Lymphocyte predominant,
Glucose - 32
Protein - 195
Chloride - 120
 GRBS at time of LP - 112mg/dl

Opthal- fundoscopy i/v/o any raised ICT for  LP

Reports
SOAP NOTES ON 25/3/22 

S: C/O fever
O: patient is drowsy but arousal
Temp : 99.1 F 
PR : 80 bpm
BP : 120/80 mmhg 
RR : 18 cpm
SPO2 : 98 % at RA 

SYSTEMIC EXAMINATION : 
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 
RESPIRATORY SYSTEM : Bilateral air entry present , clear 
PA : soft and non tender
CNS:E4V4M6, 
pupils B/L NSRL
power- moving all limbs
tone- Increase in upper limbs and normal in lower limbs
reflex- 
             B   T   S    K     A
     UL   ++   -   -    ++     -
     LL   ++   -    -     ++    -

A: fever with altered sensorium secondary to meningitis ? pyogenic or TB
P:IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 4 MG IV /BD
TAB DOLO 650 MG RT/SOS
BP,PR monitoring 4 th hourly
INJ . THIAMINE 1 amp in 100 ml NS IV/OD
INJ. OPTINEURON 1 amp in 500 ml NS
INJ.DOXY 100 MG IV /BD
INJ VANCOMYCIN 2 gm iv Stat


Soap notes on 26/3/22 and 27/3/2022

S: reduced fever and altered sensorium
O: patient is drowsy but arousal
Temp : 98.1 F 
PR : 82 bpm
BP : 120/80 mmhg 
RR : 16 cpm
SPO2 : 98 % at RA 

SYSTEMIC EXAMINATION : 
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 
RESPIRATORY SYSTEM : Bilateral air entry present , clear 
PA : soft and non tender
CNS:E4V4M6, 
pupils B/L NSRL
power- moving all limbs
tone- Increase in upper limbs and normal in lower limbs
reflex- 
             B T S K A
     UL ++ - - ++ -
     LL ++ - - ++ -

A: fever with altered sensorium secondary to meningitis ? pyogenic or TB
P:IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 4 MG IV /BD
TAB DOLO 650 MG RT/SOS
BP,PR monitoring 4 th hourly
INJ . THIAMINE 1 amp in 100 ml NS IV/OD
INJ. OPTINEURON 1 amp in 500 ml NS
INJ.DOXY 100 MG IV /BD
INJ VANCOMYCIN 2 gm iv Stat

Soap notes on 28/3/22

S: reduced fever and altered sensorium
O: patient is drowsy but arousal
Temp : 98.4  F 
PR : 82 bpm
BP : 100/80 mmhg 
RR : 17 cpm
SPO2 : 98 % at RA 

SYSTEMIC EXAMINATION : 
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 
RESPIRATORY SYSTEM : Bilateral air entry present , clear 
PA : soft and non tender
CNS:E4V5M6, 
pupils B/L NSRL
power- moving all limbs
tone- Increase in upper limbs and normal in lower limbs
reflex- 
             B T S K A
     UL ++ - - ++ -
     LL ++ - - ++ -

A: fever with altered sensorium secondary to meningitis ? pyogenic or TB
P:IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 4 MG IV /BD
TAB DOLO 650 MG RT/SOS
BP,PR monitoring 4 th hourly
INJ . THIAMINE 1 amp in 100 ml NS IV/OD
INJ. OPTINEURON 1 amp in 500 ml NS
INJ.DOXY 100 MG IV /BD
INJ VANCOMYCIN 2 gm iv Stat

Soap notes on 29/3/22

S: reduced fever and altered sensorium
O: patient is conscious, coherent
Temp : 98.1 F 
PR : 80 bpm
BP : 100/80 mmhg 
RR : 17 cpm
SPO2 : 98 % at RA 
SYSTEMIC EXAMINATION : 
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard 
RESPIRATORY SYSTEM : Bilateral air entry present , clear 
PA : soft and non tender
CNS:E4V5M6, 

A: fever with altered sensorium secondary to meningitis ? pyogenic or TB
P:IVF NS ,RL ,DNS@100 ml/hr
INJ PANTOP 40 MG IV/OD
INJ.NEOMOL 1 GM IV SOS
INJ. MONOCEF 2 GM IV BD
INJ. DEXA 4 MG IV /BD
TAB DOLO 650 MG RT/SOS
BP,PR monitoring 4 th hourly
INJ . THIAMINE 1 amp in 100 ml NS IV/OD
INJ. OPTINEURON 1 amp in 500 ml NS
INJ.DOXY 100 MG IV /BD
INJ VANCOMYCIN 2 gm iv Stat

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