50 yr old male
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50 yrs male resident of miryalaguda c/o fever and altered sensorium
Fever: high grade associated with chills and rigor not associated with loose stools head ache,cold,cough,seizerus and loss of consciousness
Pt was apparently asymptomatic 6 yrs back then he had thrown prick to right leg because of nonhealing ulcer on routine investigation he was diagnosed with dm and htn and on irregular medication
2 yrs back complaints of pedal edema insidious onset gradullay progressive extent up to b/l knee not associated with decreased urine output facial puffiness frothing urine
Pt was admitted in hyd with c/o pedal edema and sob and diagogoned with renal failure ,5 dialysis sessions were done
Since then pt was on medical management pt had no complaints for 8 months
Then developed vomiting and loose stools 15 days back visited our hospital and pt was innitiated on dialysis in view of metabolic acidosis
Pt was twice weekly on dialysis
PERSONAL HISTORY
Married
Occupation : daily wage worker
Diet : mixed
Appetite : decreased
Bowel and bladder : Regular
No addictions .
No known allergies .
FAMILY HISTORY
K/C/O HTN , DM on medcation which are not known
GENERAL EXAMINATION
Patient is altered sensorium
No Pallor, icterus ,cyanosis, clubbing , lymphadenopathy , edema.
VITALS
TEMP : 98.6
BP : 120/ 80 mmhg
PR : 92/ min
RR : 20/ min
Spo2 : 98% on RA
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
CNS :
PATIENT IS altered sensorium not orinted with time place person
SPEECH : SLURRED
SENSORY SYSTEM : INTACT
MOTOR SYSTEM :
R L
TONE UL Increased. -
LL Hypotonic -
POWER UL 1/5 3/5
LL 1/5 3/5
REFLEXES
B T S K A P
R 1+ 1+ - - - Flexor
L 1+ 1+ 1+ - - Flexor
Gcs: E4V1M4
Meningeal signs: neck stiffness +
Diagnosis: chronic kidney disease on maintaining hemodilysis with acute pyogenic bacterial meningitis ? With k/c/o DM ,htn
Reports :
25/10/21
ECG:
BGT:AB POSITIVE
SEROLOGY : NEGATIVE
ECG ON 24/11
XRAY ON 27/11
2D ECHO ON 24/11
Review 2d echo
Blood urea:266
Serum creatinine:6.3
Uric acid:8.1
Na-139
K-3.6
Cl-92
TREATMENT GIVEN :
HEMODIALYSIS on 25/10/21,28/10/21,2/11/21,6/11/21, 21/11/21(WITH PRBC), 24/11/21( with PRBC),25/11/21 ( WITH PRBC)
Inj DEXAMETHASONE 8 MG IV/BD
RT FEEDS -100ML MILK@4TH HOURLY
- 100 ML WATER @ 4TH HOURLY
INJ PAN 40 MG IV OD
TAB NODOSIS 500 MG /RT/BD
TAB SHELCAL CT RT/OD
TAB OROFER XT RT/BD
INJ ERYTHROPOIETIN 4000 IU /SC/WEEKLY ONCE
INJ FALCIGO 120 MG IV (0,12,24,48 HRS )
INJ MEROPENAM 500 mg IV/BD
FLUID RESTRICTION < 1 L / DAY
SALT RESTRICTION <2 gm /day
INJ HAI S/C ( INFORM GRBS TO PG)
Soap notes :26/11/21
S- fever spikes+, fluctuating between drowsiness and aggitated state.
O- pt is c/c/c
GCS:E3,V1,M3
palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.
afebrile
pr-86/min
bp-120/80mmhg
spo2-98%with 6lit o2
r.s-bae+end insp crepts in rt isa,iaa
r.r-20/min
cvs:s1,s2+
p/a:soft,nt
cns:pupils: normal size sluggish reaction to light
reflexes: b t s k a :absent
plantars: b/l upgoing
brudzink's :+
kernig's:+
speech:aphasia
grbs-8am-222mg/dl-8hai
i/o:800/300ml since 8hrs
egfr:12.8ml/min/1.73m2
one session of HD yesterday
A- aphasia with altered sensorium secondary to meningoencephalitis ? bacterial
?DIC sec to sepsis
chronic kidney disease oh HD
dm2
anaemia, thrombocytopenia
P- rt feeds
inj dexamethasone 8mg/iv/bd
inj meropenem 500mg/iv/bd
tab pcm 650mg/rt/sos
Soap notes 27/11/21
S- no fever spike since 8am yesterday
did not pass stool since 4 days
loss of speech
aggitated in between
awake for most time compared to yesterday.
O- pt is conscious,not coherent,not
GCS:E4 V1,M4
palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.
afebrile
pr-89/min
bp-110/70mmhg
spo2-94%with 2lit o2
r.s-bae+end insp crepts in rt isa,iaa
r.r-18/min
cvs:s1,s2+
p/a:soft,nt bs+
cns:pupils: normal size sluggish reaction to light
reflexes: b t s k a :absent
plantars: b/l upgoing
brudzink's :+
kernig's:+
speech:aphasia
grbs-8am-195/dl-8hai
i/o:1000/650 since 8hrs
egfr:12.8ml/min/1.73m2
2FFP's transfused yesterday
blood and csf culture negative for any growth
A- aphasia with altered sensorium secondary to meningoencephalitis ? pyogenic ?tubercular
?DIC sec to sepsis
chronic kidney disease oh HD
dm2
anaemia, thrombocytopenia
P- rt feeds
inj dexamethasone 8mg/iv/bd
inj meropenem 500mg/iv/bd
tab pcm 650mg/rt/sos
tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD
28/11/21
S-
loss of speech+
Awake and alert for most of the time
Fever spikes +
O- pt is conscious, coherent,
GCS:E4 V1,M6
palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.
afebrile
pr-85/min
bp-110/70mmhg
spo2-98%with 3lit o2
r.s-bae+
r.r-15/min
cvs:s1,s2+
p/a:soft,nt bs+
cns:pupils: normal size sluggish reaction to light
reflexes: b t s k a :absent
plantars: b/l upgoing
brudzink's :+
kernig's:+
speech:aphasia
grbs-8am-204/dl-6hai
i/o:1500/500
egfr:12.8ml/min/1.73m2
2FFP's transfused yesterday
blood and csf culture negative for any growth
A- aphasia with altered sensorium secondary to meningoencephalitis ? pyogenic ?tubercular
?DIC sec to sepsis
chronic kidney disease oh HD
dm2
anaemia, thrombocytopenia
P- rt feeds
inj dexamethasone 8mg/iv/bd
inj meropenem 500mg/iv/bd
tab pcm 650mg/rt/sos
tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD
29/11/21
S- one fever spike at 6pm 100F
passed stools today
able to talk, asking for rice to eat
O- pt is conscious,coherent,oriented to person,place
palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.
afebrile
pr-103/min
bp-130/70mmhg
spo2-92%on ra
r.s-bae+end insp crepts in rt isa
r.r-18/min
cvs:s1,s2+
p/a:soft,nt bs+
cns:pupils: normal size sluggish reaction to light
reflexes: b t s k a :absent
plantars: b/l upgoing
brudzink's :+
kernig's:+
speech:naming+
non fluent+no repetition
grbs-187mg/dl-4units hai
i/o:1500/500 ml
egfr:12.8ml/min/1.73m2
blood and csf culture negative for any growth
A- aphasia with altered sensorium resolved) secondary to meningoencephalitis ? pyogenic ?tubercular
DIC sec to sepsis -resolving
chronic kidney disease oh HD
dm2
anaemia, thrombocytopenia(improving 25k-40k)
P- rt feeds
inj dexamethasone 8mg/iv/bd
inj meropenem 500mg/iv/bd
tab pcm 650mg/rt/sos
tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD
csf-cbnaat pending.
30/11/21
Soap notes
S- pt' is talking one or two words, awake for lesser period than before.
one episode of svt (af)-post dialysis with hr -180-190/min,resolved with injection metoprolol 5mg.
O- pt is conscious,coherent,oriented to person,place
afebrile
palpable petechiae on the palms and soles ,dermatology opinion taken- purpura fulminans.
afebrile
pr-101/min
bp-120/80 mmhg
spo2-92%on ra
r.s-bae+end insp crepts in rt isa
r.r-22/ min
cvs:s1,s2+
p/a:soft,nt bs+
cns:pupils: normal size sluggish reaction to light
reflexes: b t s k a :absent
plantars: b/l upgoing
brudzink's :+
kernig's:+
speech:naming+
non fluent+no repetition
grbs-167 mg/dl
i/o:1150/1300
egfr:12.8ml/min/1.73m2
blood and csf culture negative for any growth
A- aphasia with altered sensorium resolved) secondary to meningoencephalitis ? pyogenic ?tubercular
DIC sec to sepsis -resolving
chronic kidney disease oh HD
dm2
anaemia, thrombocytopenia(improving 25k-40k)
P- rt feeds
inj dexamethasone 8mg/iv/bd
inj meropenem 500mg/iv/bd
tab pcm 650mg/rt/sos
tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD
1/12/21
Soap notes
S- no fever spikes, talking to his relatives but hes asleep for longer time.
O- pt is conscious,coherent,oriented to person,place
afebrile
palpable petechiae on the palms + soles ,dermatology opinion taken- purpura fulminans.
afebrile
pr-105/min
bp-120/80 mmhg
spo2-92%on ra
r.s-bae+nvbs
r.r-1 2 min
cvs:s1,s2+
p/a:soft,nt bs+
cns:pupils: nsrl
reflexes: b t s k a :absent
plantars: b/l flexor
brudzink's :+
kernig's:-
speech:naming+ fluency improved, repetition still the same
grbs-122mg/dl
i/o:1100ml/450ml
egfr:12.8ml/min/1.73m2
A- aphasia with altered sensorium resolved) secondary to meningoencephalitis ? pyogenic ?tubercular
DIC sec to sepsis -resolved
chronic kidney disease oh HD
dm2
anaemia,
thrombocytopenia-resolved
P- rt feeds
inj dexamethasone 8mg stopped
inj meropenem 500mg/iv/bd-plan to make it od and stop.
tab pcm 650mg/rt/sos
tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD
2/12/21
S- 1 fever spike +, talking to his relatives.
O- pt is conscious,coherent,oriented to person,place
afebrile
palpable petechiae on the palms + soles ,dermatology opinion taken- purpura fulminans.
afebrile
pr-102/min
bp-110/70 mmhg
spo2-95%on ra
r.s-bae+nvbs
r.r-14 cpm
cvs:s1,s2+
p/a:soft,nt bs+
cns:pupils: nsrl
reflexes: b t s k a :absent
plantars: b/l flexor
brudzink's :+
kernig's:-
speech:naming+ fluency improved, repetition still the same
grbs-195mg/dl
i/o:800ml/400ml
A- aphasia with altered sensorium resolved) secondary to meningoencephalitis ? pyogenic ?tubercular
DIC sec to sepsis -resolved
chronic kidney disease on HD
dm2
anaemia,
thrombocytopenia-resolved
P- rt feeds
inj meropenem 500mg/iv/bd-plan to make it od and stop.
tab pcm 650mg/rt/sos
tab att- H-300mg,R-600mg,Z-1500 mg,E-900/RT/OD
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