Medicine case

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A 20 year old milk supplier from eklur nalgonda who is a known case of retroviral disease diagnosed 1 year back came to the casualty with altered sensorium. He had 2episodes of seizures with generalised tonic clinic movements with 5min  gap in between each episode lasting for 5mins. It is associated with involuntary micturition , and has postictal confusion .Not associated with uprolling  of eyeballs, tongue bite. He was previously admitted in the hospital with complaints of headache , vomiting , low grade fever where he was diagnosed with ( multiple ring enhancing lesions) tuberculoma and is on antitubercular treatment since 1 year

Past history:not a known case of hypertension,diabetes mellitus,asthma,chronic heart and kidney diseases

                      
Personal history:
                           Diet:mixed
                            Appetite:normal
                             Sleep: adequate
                             Bowel and bladder movements  
                              Are regular
                            No addictions

  
Family history:Both  His parents are retropositive and died  
                           8years back

Drug history: not allergic to any known drugs

General examination:

Patient is in altered sensorium,  not oriented to time ,place, and person, thin built, ill nourished
No signs of Pallor, icterus , cyanosis , clubbing , lymphadenopathy , edema
Vitals
Temparature: febrile
Pulse rate: 70bpm
BP:120/80 mm hg
Respiratory rate: 20 cycles/min

Systemic examination:
CNS examination:
    On the day of admission (22/6/2020),patient was altered but not oriented to time , place, person
GCS-  E3V4M4
 Pupils are dilated, reacting to light
Tone  elicited and power (3/5)
All the reflexes were exaggerated (3/5)


Course in hospital:
 On 23/6/2020:
Patient is agitated,not oriented to time,place,person
Sensory system: cannot be elicited
Motor system: tone  normal and power (3/5)
  Reflexes: exaggerated 
Pupils: middilated,sluggish reaction to light
no signs of meningeal irritation

On 24/6/2020: 
Patient is oriented to person, time, place but is still agitated
Sensory system :cannot be elicited
Motor system: tone and power are normal
Reflexes: exaggerated 
Lumbar puncture was done

On 25/6/2020:
  Patient is conscious,coherent and cooperative 
Higher mental functions are intact
 Sensory system:normal
Motor system:tone and power normal
Reflexes: exaggerated
Right paratracheal lymph node are palpable


On 26/6/2020:
 Patient is conscious,coherent,cooperative
Higher mental functions are intact
Sensory system : normal
Motor system:tone and power are normal
Reflexes:exaggerated

Respiratory system: 
  Bilateral air entry is Present
 
CVS:
S1 ,S2 are heard
No murmurs

Perabdomen:
Soft ,non tender
No organomegaly


















Investigations:








 





HIV-- reactive.








These are HRCT images taken 1 year back




Multiple ring enhancing  lesions (these are previous MRI)






These are new MRI pictures











Lumbar puncture procedure was done.





CBNAAT was done- which is negative
    
Provisional diagnosis:
1.Meningoencephalitis (secondary to 
?toxoplasma, ? Tubercular,?viral
2.pulmonary TB since 2years, 
k/c/o RVD ,CNS tuberculoma with mesenteric lymphadenopathy since 1year 



Treatment: 
 1.Inj.piptaz 4.5 gm/IV/TID
 2.Inj.pantop 40mg /IV/OD
 3.Inj.Levipil 500 mg /IV/BD
 4.T.BacterimDS (800/160 mg) PO/BD
 5.Inj.Mannitol 100 ml/IV/BD
 6.Inj.Optineuron 1amp in 100 ml NS/IV/OD
 7.Continue ATT Regimen  and ART regimen 
 8.Inj. Neomol 100ml/IV/SOS 
 9.T.PCM 650 mg /PO//SOS
 10.Inj. Lorazepam 2cc /IV/SOS
 






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