PATIENT IDENTIFICATION

NAME : svendu kumar swain

AGE: 16 SEX: male
RELIGION: hindu
OCCUPATION : student
MARITAL STATUS: unmarried
IP NO: KIMSIP 190980285 WARD: neurosurgery ward
DATE OF ADMISSION: 20/06/2021
ADDRESS: Athaghar ,cuttack
PROVISIONAL/ FINAL DIAGNOSIS: ENCHEPHALITIS
DATE OF SURGERY,IF ANY: No
PRESENTING CHIEF COMPLAINTS : generalized tonic-clonic seizure ,sever headach,
dizzeness, vomiting , fever .
PAST HISTORY OF ILLNESS: history of recurrent fever from last 3 month
FAMILY HISTORY:
TYPE OF FAMILY:- Neuclear
NO OF FAMILY MEMBER: -4
HISTORY OF ANY ILLNESS:- no such history of clinical illness
FAMILY TREE

KEY:-

Male:-

Patient:-

Female :-
S.N Name of the family age sex Relation education occupatio Marital Health
o member ship n status status
with pt.

1 Sankar swain. 50 M father B.Ed Teacher married good

2 Pusparani swain. 46 F Mother +2 housewife Married good

3 Subhra swain. 22 F Sister B.tech student unMarrie Good

d
4 Suvendu kumar swain. 16 M Self 10th class Student unmarried Encheph
alitis .

 SOCIO-ECONOMIC STATUS
 Name of the place:- city
 Type of house:- puccka Ventilation :- Adequate
 Water supply: supply Sanitation:- water seal
 Surrounding cleanliness:- clean Income per month:- 40.000aprx.
 Relationship among the family member:- good
MENTAL AND EMOTIONAL STATUS :- Psychological status of the family member is
normal , stress due to hospitalization.
PERSONAL HISTORY
Personal hygiene
 Oral hygiene: maintained
 Bath :- 1time / sponging 2-3 times
 Rest & sleep:- 11-12hr
DIETARY HISTORY
 General appearance: healthy Appetite: good
 Diet: normal No. of meals per day: -3times / day
 Fruit/ juice: 2-3 times in week
 No .of glasses of water per day: 6-7glasses Tea/coffee:- no

ELIMINATION
 Bowel:- loss motion Bladder:- continance

PHYSICAL EXAMINATION
GENERAL APPEARANCE
 Level of consciousness:conscious
 Hight :- 4ft 4inh Weight :- 42kg
 Activity :- dull
 Body built:- moderate

VITAL SIGNS:
 TEMP PULSE RESPIRATION BP
20/06/2021 102.3f 110 b / min 44b/m 110/80mmhg

HEAD:-
 Size & shape: round
 Hair color:- black hair distribution:- normal
 Scalp: no injury pediculosis: not present
 Swelling or tenderness:no previous injuries:- no
FACE:
 Appearance of face : no swelling Facial symmetry : normal

EYES:
 Eyes brows: normal eye lids/lashes: no injury
 Eye balls: normal lacrimal sac : normal
 Conjunctiva: red sclera:- red
 Cornea: normal pupils: reacting to light
 Blurred vision: absent eye discharge: no
 Visual acuity :- 6/6

EARS:
 Position: normal Ear wax: not present
 tympanic membrane: normal shape &size: normal
 Hearing acuity: normal foreign bodies: absent
 Any discharge: no swelling: absent

NOSE:
 Nasal symmetry: normal Nasall septal deviation : normal
 Nasal discharge: present Epistaxis: some time
MOUTH & THROAT:
 Lips: symetry shape: normal
 condition: normal dental caries: no
 Gums: swelling buccal mucosa: sore present
 Lymph node :no enlargement thyroid: normal

RESPIRATORY SYSTEM:-
 Respiratory rate: 46b/min
 Thoracic cage: normal Configuration: normal
 Skin color and condition: normal chest expansion: symmetric
 Diaphragmatic excursion: normal lung auscultation: normal
 Breath sound: bronchial Respiratory pattern :normal
CARDIOVASCULAR SYSTEM:
 Pulse: 116b/m heart sound s1 s2 :-normal
 abnormal heart sound : no BP::110/60hhmg
 Peripheral pulses: normal murmurs: absent
 Cyanosis: absent Edema: absent

GASTRO-INTESTINAL SYSTEM:
 a)Inspection:
 Skin: turgor abdomen: symmetrical
 Abdominal pain: no
 constipation: no
b)Auscultation:
 Bowel sounds: normal
c)Percussion:
 Ascitis/peritonitis: absent No gas/ fluid collection: not
present.
d) Palpation:
 Organomegaly/hepatomegaly/splenomegaly /: splenomegaly present
 Tenderness or indurations: absent Fluid collection: no
 Masses/soft: soft
GENITO-URINARY SYSTEM:
 Urinary frequency : normal Urinary patterns: normal
 Hematuria: absent Bladder distension: present
NEUROLOGICAL SYSTEM:
1.MENTAL STATUS EXAMINATION

A. GENERAL MENTAL STATUS EXAMINATION

o Level of consciousness GCS- 15/15
o Posture- normal
o Body movements- present
o Facial expression:- anxious
o Dressing & grooming:- normal
o Personal hygiene:- maintained
o Speech:- spontaneous
o Mood:- anxious
o Feelings & expression:- depressed
o Thought process & perception:-normal

B.COGNITIVE FUNCTION -NEUROPSYCHIATRIC ASSESSMENT

 Consciousness: GCS -15/15

 Attention: normally aroused
 Concentrationn:- normally sustained.

MEMORY: :- Patient memory is intact. Normal

INTELLIGENCE: normal

JUDGMENT :-intact

INSHIGHT :- True emotional inshight

 2.CRANIAL NERVES
 Cranial nerve I -Olfactory :- sense of small is normal.
 Cranial nerve II-optic :- visual problem is present.
 Cranial nerve III,IV,VI :- constricts simultaneously,papillary response is present,
 Cranial V-Trigeminal:- temporal & massester muscles contract bilaterally,eyelids blink
bilaterally.
 Cranial nearve VII –Facial :- facial movement is present.
 Cranial nerve VIII- Vestibulocochlear:- hearing and balance is normal.
 Cranial nerve IX-glossopharyngeal & X-Vagus:- gag reflex and palate movemt is present.
 Cranial nerve XI-Spinal accessory:- movement of shoulder and head rotation is normal.
 Cranial nerve XII- Hypoglossal:- toung movement and test sensation is normal.
3.MOTOR AND CEREBELLAR SYSTEMS
 Condition and movement of muscles:- power is normal. Gread 4
 Balance &Coordination:- is present.
4.SENSORY SYSTEM:-
 Light touch,pain and tempereture sensations:- present of sensations
 Vibratory sensation:- able to feel.
 Tactile discrimination:- able to recognized.
5.REFLEXES :-
 Biceps reflex:-
 Brachioradialis reflex:-
 Triceps reflex:-
 Patellar reflex:- Present
 Achilles reflex:-
 Ankle reflex:-
 Superficial reflexes:-
 Abdominal reflex:-
TESTS FOR MENINGEAL IRRITATION OR INFLAMMATION
1. Brudzinki’s sign :- absent
2. Kernig’s sign.-absent

INTEGUMENTARY SYSTEM:
 Skin color: normal Skin texture :- moist
 Skin integrity :intact Temp: warm
 Turgor / mobility elastic Edema: absent
 Lesions : no Bluish discoloration: abesent
 Clubbing of nail : absent
 BLOOD INVESTIGATION REPORT:-
BLOOD GROUP – B +VE.

SL NO TEST NAME PT.VALUE NORMAL UNITS REMARK

VALUE
1. WBC 12.950 4.00-10.00 10 3/ul High
2. RBC 4.12 4.5-5.5 10 6/ul Low
3. HB% 11.2 13-17 % Low
4. PCV 47.3 40.0-50.0 % Normal
5. MCV 94.59 83-101 1L/UM3 Normal
6. PLTC 227 150-410 10 3/UL Normal
7. S.UR 34 12-43 Mg/dl Normal
8. S.CR 1.9 0.9-1.3 Mg/dl High
9. S.NA 137 136-145 Mmol/l Normal
10. S.K 3.8 3.5-5.1 Mmol/l Normal
11. Sr.BILURUBIN(total) 0.83 0.13-1.20 DL
12. C-reactive protein 1.2 mg/dl ,0–0.5 mg dl High
CSF STUDY :-
 Cerebrospinal fluid (CSF) tests is positive:
 Glycorrhachia - 141 mg/dl (normal range, 50–80 mg/dl)
 Proteinorrachia : normal
 CSF white cell count - 135/UI (normal range, 0–5/UI)
 left shift (90% neutrophils and 10% lymphocytes).

REDIOLOGICAL INVESTIGATION
Brain computerized tomography (CT) and MRI were normal. CSF showed mildly
elevated lymphocytes and protein .
Continuous EEG demonstrated non-convulsive status epilepticus
Anti-NMDA-R antibodies were detected in serum and CSF
SUMMARY:-

Brief description about - ENCEPHALITIS

 Encephalitis is an inflammation of the brain. Usually the cause is a viral infection, but bacteria
can also cause it. It can be mild or severe. Most cases are mild. Patients may have flu-like
symptoms. With a mild case, Severe cases need immediate treatment. Symptoms of severe
cases include:

 Severe headache
 Sudden fever
 Drowsiness
 Vomiting
 Confusion
 Seizures
 In babies, additional symptoms may include constant crying, poor feeding, body stiffness,
and bulging in the soft spots of the skull.

DIAGNOSTIC STUDY :-
 Cerebrospinal Fluid (CSF) Analysis   
 Computed Tomography (CT) -- Head
 EEG (Electroencephalogram) 
 Magnetic Resonance, Functional (fMRI) -- Brain

TREATMENTS:

 include oral and intravenous (IV) medicines to reduce inflammation and treat infection.i.e
acyclovir treatment at a dose of 750 mg/250 ml in 3 h three times a day.
 Patients with breathing difficulties may need artificial respiration. Some people may need
physical, speech, and occupational therapy once the illness is under control.