70yr old male with altered sensorium secondary to ?Meningitis

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

A 70 Years Old Man Who was a Farmer By Occupation Presented to Casualty With 

Altered Sensorium Since 3 Days 

Fever Since 20 Days 

HOPI : 

Patient Was Apparently Asymptomatic Till 2014 ;

2014 - Patient Had Fever Associated with Cough for which he went to Hospital & Was Diagnosed to Have ? Pneumonia with DENOVO DM2 & Was Prescribed with OHAs ( Tab.METFORMIN & Tab.GLIMIPRIDE )

6 Months Back - Patient Had Fever Associated with Cough for Which he Went to Hospital & Said to Have High Sugars along with Lung Infection ; Got Treated & Discharged in a Hemodynamically Stable Manner.Started using insulin for Diabetes Since Then 

20 Days Back : Patient Had Fever with Cough ; For Which He went to Hospital & Suspected to Have TB But Reports Turned out to be Negative & Patient Discharged as LAMA & When He Returned Home 3 Days Back He Gradually Developed Altered Sensorium & Couldn't Recognise His Attendants

Past History :

K/C/O DM2 Since 9 Years and on Regular Medications

N/K/C/O HTN ; TB ; EPILEPSY ; ASTHMA 

Addictions : 

He Started Consumption of Alcohol at the age of 20years & It became a habit to drink 90ml per Day Till 6 Months Back

He Started Smoking Beedis at the age of 20 Years & It Became a Habit to Smoke 20 Beedis Per Day 

On Presentation : 

BP - 110/80mmHg

PR - 110/min

Temp - 102.5 F

RR - 22/min 

Spo2 - 98% @RA

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E2V2M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone - Normal in Both UL & Hypertonia in Both lower limbs

Power - 4/5 In all 4 Limbs

Reflexes - B T S K A - 2+ 

Plantars - RT - Mute & Left - Flexor

Investigations -

ECG-

S. Urea-24mg/dl

S creatine-0. 8mg/dl

S. Electrolytes -

Na+-132

K+- 3.6

Cl- 98

Ca2+ 1.20

LFT-

Hemogram-

Rbs-157mg/dl

HbA1c-6. 8%

ABG-

Chest XRay-

CSF analysis-

glucose -42

Protein -60

Cl-121

ADA-131

CSF CELL COUNT

Vol-0. 5 ml

Color- colorless

Appearance- clear

Total count-104 cells

DC-

60% lymphocytes

20% monocytes

20% neutrophils 

Others- nil

RBC- nil

Rules tube content 

Provisional diagnosis -

?TB meningitis

Treatment -

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @50 ml/hr

Inj. Ceftriaxone 2 GM iv stat

Then inj . Ceftriaxone 1 GM iv bd

Inj Dexa 6 mg iv stat then 

Inj. Dexa 6mg iv tid

Monitor vitals 2 nd hourly

Grbs monitoring

Strict input and output charting

Inj. Neomol 1 GM iv /sos ( if temp>101F)

16/02/23

70 year old man c/o fever since 20 days and altered sensorium since 3 days

S-

No fever spikes

Patient obeying to commands

O-

BP - 120/70mmHg

PR - 98/min

Temp - 98F

RR - 22/min 

Spo2 - 98% @RA

Grbs-250 mg/dl

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E2V2M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

A-

Altered sensorium under evaluation secondary to? meningitis 

?TB meningitis

Investigations -

Hb- 12.0g/dl

TLC- 8700

PLC- 3.02LAKHS

Lymphocytes -32

Pcv-35. 2

S Urea-24mg/dl

S creatine-0. 8mg/dl

S. Electrolytes -

Na+-132

K+- 3.6

Cl- 98

Ca2+ 1.20

LFT-

Total bilirubin-0. 9

ALP-144

Total proteins-6. 2

Albumin-3. 0

Rbs-157mg/dl

HbA1c- 6.8%

P-

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @50 ml/hr

Inj. Ceftriaxone 2 GM iv stat

Then inj . Ceftriaxone 1 GM iv bd

Inj Dexa 6 mg iv stat then 

Inj. Dexa 6mg iv tid

Monitor vitals 2 nd hourly

Grbs monitoring

Strict input and output charting

Inj. Neomol 1 GM iv /sos ( if temp>101F)

Inj. HAI S/C according to grbs

17/02/23

70 year old man c/o fever since 20 days and altered sensorium since 3 days

S-

No fever spikes

Patient obeying to commands

Hiccups since yesterday afternoon 

O-

BP - 110/70mmHg

PR - 66/min

Temp - 95.5F

RR - 22/min 

Spo2 - 98% @RA

Grbs-

15/2/23

8am-250mg/dl

2pm-269mg/dl

4pm-272mg/dl

8pm-278mg/dl

16/2/23

2am - 200 mg/dl

8am - 250mg /dl

2pm 265mg/dl

8pm 140mg/dl

10pm 191 mg/dl

17/2/23

2am 197 mg/dl

8am 175mg/dl

Input-2300ml

Out put-1000ml

CVS - S1S2 Heard & No Murmurs 

RS - BAE + ; NVBS + 

P/A - Soft & Non Tender

CNS - 

GCS - E3V3M5

RT Pupil - Couldn't be assessed

Lt Pupil - NSRL

Tone- normal in all 4 limbs 

Power- 4/5 in all 4 limbs 

A-

Altered sensorium(resolving) secondary to meningoencephalitis secondary to tuberculosis

K/c/o DM since 9 years

Investigations -

Hb- 11.5g/dl

TLC- 11000

PLC- 3.08LAKHS

Neutrophils -85

Lymphocytes -09

Pcv 34.6

RBC count 3.08

15/2/23

S.Electrolytes -

Na-135

K-4. 3

Cl-102

Ca2+1. 12

P-

Ryles tube feeds-200 ml milk every 4 th hourly

100 ml water every hourly

Iv fluids NS @100 ml/hr

Inj. Dexa 6mg iv tid day 3

Inj human actrapid s/c according to GRBS 

Tab. Isoniazid 275 mg (4tabs po/od) morning

Tab. Rifampicin 550 mg (4tabs po/od morning

Tab. Pyrazinamide 1550mg (4tabs po od morning

Tab ethambutol 825 mg po od morning

Grbs 7 th hourly

Inj. neomol 1 g iv sos( if temp >101F)

Strict input output charting 

Grbs monitoring

Tab benadone 40mg po/od

Tab baclofen 10mg po/sos

Inj perinorm 10mg iv stat 

Inj pan 40mg iv/od

Beautiful Orange colored urine is seen might be due to antitubercular therapy - Rifampicin