Final exam Short case
Name: M.Tejaswini
Halltkt:1701006107
A 55yr old female came with chief complaints of:
-fever since 4 days
-headache since 4 days
History of present illness
Patient was apparently asymptomatic 4 days back then she developed fever which was insidious in onset, continous type relieved with medication and not associated with chills and rigors.
Fever was associated with diffuse headache which was throbbing type present throughout the day and relieved with medication.
There was 1 episode of vomiting which non projectile, non bilious, content was food.
She also had neck stiffness.
There's no history of photophobia, giddiness,seizures.
Past history
No similar complaints in past
Not a known case of DM, HTN, TB, asthma, epilepsy
Personal history
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder: regular
No addictions
No known drug and food allergies
Family history
Not significant
General examination
Patient is conscious, coherent, coperative. Moderately built moderately nourished
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals:
temperature:99.3F
Pulse rate: 78bpm
Resp rate:18cpm
BP:120/80mmhg
Spo2:99%
Systemic examination
1)Central nervous system
-Higher mental functions: intact
-Cranial nerve examination: normal
-Sensory system examination: normal
-Motor system examination:
Bulk,tone and power of the muscles is normal
-reflexes: normal
-meningeal signs:
Brudzinski: positive
Kernigs: positive
2)Respiratory system
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
3)CARDIOVASCULAR SYSTEM:
Inspection:
Shape of chest- elliptical
No precordial bulge or pulsations
JVP - not raised
Palpation:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation , S1 S2 heard No murmurs
4)PER ABDOMEN:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
Percussion - tympanic note heard
Auscultation- normal bowel sounds heard
Provisional diagnosis:
Meningitis
Investigations:
Complete blood picture
CSF analysis
Sugar:81
Proteins:12.6
Chloride: 113
Skull xray:
NS1 antigen is positive
ECG
Chest xray:
MRI
Treatment:
- inj Ceftriaxone 2gm IV BD
-Inj dexamethasone 6mg IV TID
-Inj vancomycin 1gm IV stat
-Tab Paracetamol 650mg TID
-syrup cremaffin.
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