13 year old male with seizures
DR.CHETANA(INTERN)
DR.ABDUL RAHEEM (INTERN)
DR.ASHFAQ(INTERN)
DR.SRAVYA(INTERN)
DR.GNANADA(INTERN)
DR.CHARAN(PG1)
DR.VAMSI(PG1)
DR.SUSMITHA(PG2)
DR.ADITHYA (PG3)
DR.PRANEETH(PG3)
DR.PRAVEEN NAIK (ASS.PROF)
DR.RAKESH BISWAS(HOD)
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Here is a case i have seen:
A 13year old boy studying 8th standard who was apparently asymptomatic 10days back came to casualty at around 10:00 pm on 25.01.2021 in a state of post ictal confusion with c/o low grade fever since 10 days, which is intermittent and associated with chills.
H/o facial puffiness and pedal edema on & off since 4 days
High coloured urine +
?frothy urine +
H/o Headache and retro orbital pain since 3-4days.
H/o vomitings since 2days,bilious ,food particles as content,non projectile,non foul smelling.
one episode on 24.01.2021,5-6episodes on 25.01.2021.
On evening of 25.01.2021 he had h/o 3-4 episodes of seizures with focally involving Rt UL and LL with secondary generalization.
Each episode lasts for 5mins ,not associated with loss of consciousness, tongue bite, involuntary micturition, defecation.
H/o post ictal confusion present lasting for 20-30min.
No H/o pain abdomen,loose stools,cold,cough.
No H/o chest pain, palpitations, sob
No H/o cold, cough
No other complaints.
Not a k/c/o DM,HTN, Asthma, epilepsy,CAD,TB.
He is a Non vegetarian with Normal appetite,has regular bowel and bladder movements.
On examination:
VITALS:
Temperature:98.4 F
Bp:120/80mm Hg
PR: 89bpm regular,normal volume
Spo2:96@Room air
RR: 18 cpm
Grbs:196mg/dl
No signs pallor ,icterus, cyanosis, clubbing, koilonychia
No generalized lymphadenopathy and pedal edema.
CVS:
S1,S2 Present
No murmurs
RS:
B/L Air entry present
Normal vesicular breath sounds heard
No added sounds
Per abdomen:
Soft,non tender
No palpable masses,no organomegaly
Bowel sounds heard.
CNS:
Higher Mental functions :Intact
No signs of meningeal irritation
(Kernigs sign_negative,Brudzinski Sign_negative)
Cranial nerves: intact
Motor system: intact
Sensory system:intact
REFLEXES RIGHT. LEFT
Biceps 2+. 2+
Triceps. 2+. 2+
Knee jerk. 2+. 2+
Ankle jerk. 2+. 2+
Plantar reflex. Flexor. Flexor
INVESTIGATIONS:
Heamogram:
Hb: 11.6gm/dl
TLC: 16,100
Neutrophils: 92 percent
Lymphocytes: 4 percent
RBC: 3.84 millions/cu.mm
Platelets: 2.48lakhs/cu.mm
CUE:
Color: reddish yellow
Appearance:hazy
Albumin: +++
Sugars: Nil
Pus cells: 2_4/HPF
Epithelial cells: 2_3/HPF
RBC: 10_15/HPF
BLEEDING TIME: 2MINS
CLOTTING TIME: 4 MINS
PT:17SECS
INR:1.22
APTT:35 SECS
SERUM CREATININE: 0.7mg/dl
SERUM ELECTROLYTES:
Sodium:140mEq/dl
Potassium:4.1 mEq/dl
Chloride: 103mEq/dl
TOTAL BILIRUBIN:0.9mg/dl
DIRECT BILIRUBIN:0.2mg/dl
Urine protein/creatinine ratio:
Spot urine protein:142mg/dl
Spot urine creatinine:34mg/dl
Ratio:4.1
CSF ANALYSIS:
Glucose: 72mg/dl
Protein: 32 mg/dl
Chloride:116 mg/dl
CSF MICROSCOPY:
CSF CYTOLOGY:
Color : colorless
Appearance:clear
Quantity:2.5ml
Total count:3cells/cu.mm
Lymphocytes:100 percent
Neutrophils:nil
RBC: Present
Others: nil
CHEST X-RAY:
T2 flair sulcal hyperintesities noted in bilateral occipital lobes,frontal lobes,parietal lobes,and rt cerebellar hemisphere
Few hyperintesities in rt occipital and rt cerebellar hemisphere shows diffusion restriction on DWI sequences
Opinion: possibility of meningoencephalitis
Serology:
Dengue IgM positive on 25th jan
Diagnosis:
ACUTE MENINGOENCEPHALITIS ?Viral
Treatment:
INJ.LORAZEPAM 2CC IV SOS
INJ.MONOCEF 1GM IV TID
INJ.VANCOMYCIN 1GM IV BD
INJ.DEXAMETHASONE 6 MG IV QID
INJ.PHENYTOIN 100 MG IV TID
TAB. PCM 500MG PO TID
INJ.ZOFER 4MG IV TID
INJ.PAN 40 MG IV OD
STRICT BP, TEMPERATURE,SPO2, PR, CHARTING 2ND HOURLY.
DR.PRAVEEN NAIK( ASS.PROF)
FACULTY AUTHOR NAME: DR.RAKESH BISWAS(HOD)
26.01.2021(Discussion and learning points)
S - Patient reporting improved appetite. Back ache is severe, at the site of LP. Mild headache +
O - Vitals - PR - 104 BPM, BP - 110/70 mm Hg Temp 100f RR - 18. Terminal neck stiffness +. Abdomen non tender. Passed semisolid stools twice today. Able to tolerate oral feeds well and is eating well. Adequately hydrated.
A - Partially treated Meningoencephalitis with Glomerulonephritis. IgM + for Dengue. No adverse reactions to Vancomycin.
P - Watchful monitoring with antipyretic control and adequate hydration.
Problem List -
Fever, vomiting, seizures, loss of appetite, back ache and edema.
Subsided - Vomiting, seizures, loss of appetite and edema ( 50%)
Persistent - Fever and back ache.
Raised JVP in patient
27.01.2021From the above problem list
New - Headache.
Subsiding - Backache.
Persistent - Low grade fever. Frothy urine and hematuria
Complete Resolution - Loss of appetite (great return of appetite), seizures and edema.
O - PR - 77 BPM BP - 130/80 mm Hg Spo2 98 on Room air GRBS 154 Temp chart shared below
A - Viral encephalitis with resolution of tachycardia and resolving fever.
P - To continue Dexa for 2 more days and plan for a taper. 5 days of Ceftriaxone and Vancomycin (Day 3 today).
28.01.2021
Subsiding- backache
Persistent- low grade fever
Complete resolution of loss of appetite, seizures
O- PR-80bpm, BP-130/90mmhg,spo2 -98 at room air
A- viral encephalitis with acute glomerulonephritis
P-continue dexa
29.01.2021
S- No headache, loss of appetite, No fever and no seizures, feeling symptomatically better
O-
BP:120/70mmHg
PR:76bpm
Temp 97.8F
RR 16
All other systems are remarkable
A - viral encephalitis with acute glumerulonephritis
P- plan for 24h urinary protein creat ratio, CUE, USG abd as advised by nephro Team.
Date - 30/ 1/2021
S- no fresh complaints
O-BP- 130 / 70 mm hgPR - 80bpm
Cvs- s1s2 heard
RS - BAE Present
Per abdomen- soft , non tender, no organomegaly
CNS - NAD
A-Viral encephalitis ? Dengue with acute glomerulonephritis
P-1.TAB .SODIUM VALPROATE 200MG/PO/BD
2.TAB .PAN 40 MG / PO/ OD
3.TAB.ZOFER 4 MG /PO/SOS
4.TAB PCM 500 MG PO TID
5.INJ .LORAZEPAM 2 CC /IV / SOS
6.BP/PR /TEMP Charting 4 th hourly
7. Strict I/O charting
8.TAB .VOVERAN 50 MG OD after food
9. stopped Tab.Dexamethasone 4mg
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