DISCHARGE SUMMARY

DEPARTMENT OF NEUROLOGY
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH
CHANDIGARH – 160012
RAMANDEEP
NAME AGE 30 SEX FEMALE
KAUR
FATHERS/
ADMISSION
HUSBAND’S AVTAR SINGH CR NO 202202679871 2022059213
NO
NAME
CONTACT
ADDRESS MULANPUR GARIBDAS MOHALI PUNJAB 7838977788
NO.
CONSULTAN PROF DR V LAL /
DOA 18-08-22 DOD 03-09-22
T DR KAMALESH
TB MENINGOENCEPHALITIS
DIAGNOSIS S/P VP SHUNT REVISION SURGERY (18/8/22)
HYPOTHYROIDISM
CHIEF COMPLAINTS
Fever since 3.5 month
Altered mental status since 2.5 month
BGH & HOPI
She was apparently well till 3.5 month ago when she developed fever- low grade, initially documented 100
degree f, not a/w chills and rigor which used to subside with oral antipyretics. It was accompanied by
headache since which used to be holocranial, occurring predominantly in occipital area, more during early
morning with VAS score of 7/10 with no relieving factors. This continued to progress until 1 month into the
illness, when she started talking irrelevantly, gradually became drowsy and became bed bound in 3-4 days
for which she presented in PGI EMOPD. She underwent NCCT Head along with CSF examination which
were s/o TB meningitis. She was then, started on ATT and Tab Dexa 8mg w.e.f of 5/6/22. She started
improving within 2 days and was discharged after 4 days. Steroids were gradually tapered to 2 mg TDS and
after 2 of which - fever recurred- low grade, not a/w chills and rigor. This was followed by recurrence of
AMS after 1 day in form of irrelevant talks. Dexa was then upgraded to 4 mg tds and sensorium improved.
Status remained same for 2 days then she again deteriorated. 3 months into illness, on 2-8-22 – MRI Brain
was done which was s/o tuberculoma with ventriculitis on left side of occipital horn of left lateral ventricle
for which he was given IV MPS pulse for 5 days after which she had some improvement transiently. In view
of persistence of drowsiness and altered sensorium, she was started on Tab levoflox 500 mg OD and Inj
streptomycin was stopped, however sensorium did not improved. CT was done which was s/o worsening
hydrocephalous. VP shunt was done on 14-8-22. She had mild improvement in 2 days and was then,
discharged on 16-8-22. She came to TBM Clinic on 18/8/22 in view of persistent altered sensorium after
which she was advised admission for further management.
Past history- Hypothyroid since 2 years on Tab Thyronorm 75 mg od.
H/o ectopic pregnancy 2 times (2020 july and 2021- june)
No h/o DM/HTN/Epilepsy
Family History:- no significant family h/o
Personal/drug history:- veg diet
No addiction
GENERAL EXAMINATION:
GCS- E4V4M6(dull)
P/I/C/C/L/E: absent
Bp- 120/80(Right arm supine position
Pulse- 98/m
RR- 18;Afebrile
98% on r/a

SYSTEMIC EXAMINATION
CVS- JVP- not elevated, S1, S2 normal. No murmur
RS- B/L normal vesicular breath sounds. No added sounds
GI- soft, no hepatosplenomegaly

CNS :
At Admission:
HMF: Could not be assessed
CRANIAL NERVES:
- CN 2 – Pupils bilateral reactive . size normal
- Light reflex
Right Left
Direct + +
Indirect + +
- Fundus- N
- CN III/IV/VI – Spontaneous Eye movements+
- V – Corneal/ conjunctival reflex + , sensory , motor and jaw jerk normal.
- VII – No facial asymmetry
- VIII to X11 – could not be assessed

MOTOR SYSTEM EXAMINATION

- Bulk: Symmetrical in bilateral upper and lower limbs.
- Tone- normal in upper limb, increased in lower limbs
- Power

On adm. On discharge
Right Left right left
Shoulder Abduction 5 5 5 5
Adduction 5 5 5 5
Flexion 5 5 5 5

Extension 5 5 5 5
Elbow Flexion 5 5 5 5
Extension 5 5 5 5
Wrist Flexion 5 5 5 5
Extension 5 5 5 5

Hand grip 100 % 100%

Right Left right left

Hip Adductors 1 1 4+ 4+
Abductors 1 1 4+ 4+
Flexor – Iliopsoas 1 1 4+ 4+
Extensors- Gluteus1 1 4+ 4+
maximus
Knee Flexor – Hamstrings 1 1 4+ 4+
 Extensor – Quadriceps 1 1 4+ 4+
Ankle Dorsiflexor – Tibialis 2 2 4+ 4+
PLANTAR FLEXION 2 3 4+ 4+
EHL weak weak 4+ 4+
Toe grip weak weak 4+ 4+

DTR B T S K A P
Right 2+ 2+ 2+ 3+ 1 flexor
Left 2+ 2+ 2+ 3+ 1 flexor
SENSORY – could not be assesed
CEREBELLUM-could not be assesed
Skull and Spine-Normal
Gait- could not be assessed

INVESTIGATIONS:

Date 18/ Aug/ 2022 24/ Aug/ 2022 31/ Aug/ 2022 04/ Sept/2022 05/Sept/2022
Hb 10.3 10.9 10.8 11.2 11.3
TLC 9200 5800 5700 4900 5300

DLC(N/L/E/M/B) 86.3/8.6/0.0/4.9/0 79.9/5.7/2.6/11.3/ 73.5/15.6/2.0/8.4/0. - -

.2 0.5 5
Platelet x 1000 304 255 222 287 309
Na /k 136.9/3.06/92.1 142/3.50/102 143.2/3.70/99.4 139/ 3.45 142/3.57
Urea/creat 15.7/0.57 30/0.61 16.8/0.72 20/0.52 16/0.6
TB/CB 0.35/0.21 0.45/0.15 0.52/0.32 - -
TP/ALB 7.66/ 4.49 8.0/4.46 7.68/4.26 - -
AST/ALT/ALP 17.9/16.2/- 17/18/- 18.4/21.7/63 - 23/38/63
INR 1.15 - - - -
TC/TG/LDL/HDL - - - - -
ESR - - - - -
CRP - - - - -
Other Investigations-
CSF examination-20/08/22- tc-59,dc-14/85(n/m)
p/s- 65/45
28/08/22- tc-10, dc-142/63
CSF gene expert (15/08/22)- negative (outside)
CE-MRI Brain reports: Done on 27/08/2022
a) Clinical details and findings: F/U/C/O TBM on ATT 5/6/2022 S/P VP shunt 4/8/2022 fb revision
on 19/08/2022. No improvement on symptoms.
b) IMPRESSION:
a. multiple ring and nodular enhancing lesions in bilateral cerebral hemisphere and Bilateral
cerebellar hemisphere and bilateralcerbral hemisphere with diffuse leptomeningeal
enhancement along sulcal spaces of b/l cerebral hemisphere and along midbrain and pons.
b. Conglomerated ring and nodular enhancing lesion along left choroid plexus with ventricular
adhesions causing hydrocephalous and mass effect in form of midline shift.
c. Conglomerated ring and disc enhancing lesions along optic chiasma and pituitary fossa.

COURSE AND MANAGEMENT:

30 year old female with 3.5 months h/o fever and headache f/b altered mental status about 2 months back.
She was diagnosed as TB meningitis and initiated on ATT w.e.f 5/6/2022 f/b development of
hydrocephalus (s/p VP Shunting-4/8/2022. In view of persistent symptomatology with GCS E2V2M5 ,
possibility of shunt failure has been kept and Shunt Revision surgery has been done on 18/8/22 and patient
has improved sensorium wise , she was managed with ATT and limb physiotherapy and is being
discharged with following advise
ADVICE ON DISCHARGE:

TAB INH 300 MG OD

Cap rifampicin 600 mg od
TAB pyrazinamide 1250 mg od
TAB THALIX 50 MG BD
TAB PYRIDOXINE 20 MG OD
TAB THYROXINE 75 mcg od
TAB LEVIPILL 500 MG BD
TAB DEXA 6 mg TDS
TAB PANTOCID 40 mg OD BBF
TAB SHELCAL 500 MG OD
TAB BENFORMET FORTE I OD
LIMB PHYSIOTHERAPY

Review after 2 weeks in tb clinic on Thursday in room no 3113 new opd with CBC , LFT

DR.SUNNY DR.SANDEEP DR. SURBHI PROF V LAL/ DR KAMALESH

BED JR BED SR WARD SR CONSULTANT