Patient was brought to casualty with c/o :-
Headache since 10 days
Fever since 10 days
Acute urinary retention since 5 days
HOPI:-
22yr old female , farmer by occupation
Patient was apparently assymptomatic 10 days back , then she had c/o Headache , diffuse in region , occipital region predominantly, Gradual in onset , dragging type , radiating to neck , Aggrevated on talking , rotating the head , relieved on medication
Associated with nausea
- Phonophobia present
- No h/o Photophobia , Lacrimation
- C/o Fever since 10 days , High grade fever associated with chills and rigors, Continous , relieved on medication , gradual in onset
- Pt c/o Vomitings , associated with nausea , Non projectile , not associated with blood
- After 5 days Pt c/o urinary retention ( acute ) , able to feel fullness of bladder , not able to pass urine , relieved after passing foleys
-No c/o cold , cough
- 5 days back Pt attenders c/o Altered Sensorium which lasted for 5 mins . Not able to recognise persons , place, time
- Had Weakness of lower limbs for 4 days . Spontaneously resolved .
- patient was not able to walk on her own during the weakness episode
- No seizures , weakness
Ophthalmology referral:-
Impression:-
Early changes of Papillodema noted ( Grade 1)
Past history:-
Not a k/c/o DM, Asthma , Epilepsy , HTN
Treatment history:-
LSCS 1 1/2 year back
Personal history:-
Married female
Appetite - decreased , improved since yesterday
Bowels- Constipation , relieved on medication
Micturition- abnormal
Addictions:- No addictions
Family history:- Not significant
General examination:-
Pt is c/c/c
Oriented to time, place , person
Pallor present
No icterus , cyanosis , clubbing , odema, lymphadenopathy
Vitals:-
Temp:- Afebrile
PR:- 110bpm
RR:- 14 /min
BP:- 100/60mmhg
Spo2:- 97%
GRBS:- 133mg%
Systemic examination:-
CVS :- S1S2 heard , No murmurs
RS:- BAE present
PA:- Soft, Non tender
CNS:- Intact
Neck stiffness:- No
Kernig sign :- No
Reflexes Right Left
Biceps. Absent. Absent
Triceps 1+ 1+
Supinator. 1+. 1+
Knee. 2+. 2+
Ankle. 1+. 1+
Plantar. Mute. Mute
Tone :- Right. Left
Upper limb. Normal. Normal
Lower limb. Normal. Normal
Power:- Right Left
Upper limb. 5/5. 5/5
Lower limb. 5/5. 5/5
- No finger nose in coordination
- No knee - heel in coordination
GAIT VIDEO:-
https://youtube.com/shorts/aOUKlG0NHu8?feature=share
LUMBAR PUNCTURE DONE ON 17/02/22
INVESTIGATIONS:-
Hemogram:-
Hb:- 13.3gm/dl
TC:- 9,200
N/L/E/M/B:- 80/15/03/02/00
MCV:- 81.1
MCHC:- 34.7
RBC count:- 4.7 millions
Platelets :- 4.3 lakhs
Smear:- Normocytic Normochromic blood picture
Aptt:- 35sec
Bleeding time :- 2min
Clotting time :- 4 min 30 sec
Prothrombin time :- 18
INR :- 1.3
RBS:- 114mg/dl
LFT:-
TB:- 0.81
DB:- 0.20
AST :- 28
ALT:- 18
AlP:- 96
TP:- 7.0
A/G Ratio:- 1.48
RFT:-
Urea :- 27
Creatinine :- 0.7
Na :- 141
K:- 4.4
Cl:- 97
CSF ANALYSIS:-
Sugar:- 74mg/dl
Protein:- 27mg/dl
Chloride:- 118mmol/L
CELL COUNT :-
TC:- 25 cells
DC:- 100% L
RBC - Nil
Chest X ray:-
Inj CEFTRIAXONE 2gm IV/ STAT
Inj OPTINEURON 1amp in 100ml NS IV/OD
BP/ PR/ RR/ SPO2 Charting
Inj Mannitol 20gm/ 100ml IV/ STAT
SOAP NOTES :-
Day 2 Of admission
AMC
BED 1
23yr/ F
S:- Headache reduced
No fever spikes
O:-
PR:- 88/min
BP:- 120/80mmhg
RR:- 16/min
Spo2:- 98%
GRBS:- 92mg/dl
CVS :- S1S2 heard
RS:- BAE +
PA:- Soft, Non tender
CNS:- Intact
Neck stiffness:- No
Kernig sign :- No
Reflexes Right Left
Biceps. Absent. Absent
Triceps 1+ 1+
Supinator. 1+. 1+
Knee. 2+. 2+
Ankle. 1+. 1+
Plantar. Mute. Mute
- Anal spinchter tone :- Normal
- No Saddle Anesthesia
- Urine output :- 1500ml
Lumbar Puncture done yesterday
CSF ANALYSIS:-
Sugar:- 74mg/dl
Protein:- 27mg/dl
Chloride:- 118mmol/l
A:- Transverse myelitis ( Resolving)?
? Meningitis
P:-
1) Inj OPTINEURON 1amp in 100ml NS/ IV/OD
2) BP/PR/ SPO2/ RR Charting
Day 3 Of Admission
WARD
23yr/ F
S:- Headache reduced
No fever spikes
O:-
PR:- 86/min
BP:- 110/70mmhg
RR:- 16/min
Spo2:- 98%
CVS :- S1S2 heard
RS:- BAE +
PA:- Soft, Non tender
CNS:- Intact
Neck stiffness:- No
Kernig sign :- No
Reflexes Right Left
Biceps. Absent. Absent
Triceps 1+ 1+
Supinator. 1+. 1+
Knee. 2+. 2+
Ankle. 1+. 1+
Plantar. Mute. Mute
- stools passed
MRI SPINE done yesterday :-
Impression:-
Longitudinal extensive transverse myelitis ( C3 to conus medullaris)
To rule out :-
- NMO/ Demyelination
- Anti MOG antibody disease
- GFAP astrocytopathy
- Sarcoidosis/ SLE
A:- Longitudinal extensive transverse myelitis (C3 to conus medullaris)
Secondary to? NMO
P:-
Day 2/5 1) INJ METHYL PRESDNISOLONE 1gm IV/OD
2) INJ OPTINEURON 1amp in 100ml NS/IV/OD
3) INJ PAN 40mg IV/OD
4) BP/ PR/RR /Spo2 CHARTING
Day 5 Of Admission
WARD
23yr/ F
https://vasishta175.blogspot.com/2022/02/admission-3-and-6-amc-bed-1-patient.html
S:- No Headache
No fever spikes
- Foleys was removed day before yesterday after which she tried to pass urine but she couldn’t
- she couldn’t sense pain in distension
- Usg abdomen was done yesterday -
Impression:- -700ml urine was seen
Again foleys was placed
O:-
PR:- 84/min
BP:- 110/70 mmhg
RR:- 17/min
Spo2:- 99%
CVS :- S1S2 heard
RS:- BAE +
PA:- Soft, Non tender
CNS:- Intact
Neck stiffness:- No
Kernig sign :- No
Reflexes Right Left
Biceps. Absent. Absent
Triceps 1+ 1+
Supinator. 1+. 1+
Knee. 2+. 2+
Ankle. 1+. 1+
Plantar. Mute.
A:- Longitudinal extensive transverse myelitis (C3 to conus medullaris)
Secondary to? NMO
P:-
Day 4/5 1) INJ METHYL PRESDNISOLONE 1gm IV/OD
2) INJ OPTINEURON 1amp in 100ml NS/IV/OD
3) INJ PAN 40mg IV/OD
4) BP/ PR/RR /Spo2 CHARTING
Comments
Post a Comment