Meningoencephalitis TB

NEUROLOGY MEDICAL RECORD

IDENTIFICATION Name: Mr. AMAge: 25 years oldSex: MaleAddress: SekayuReligion: IslamAdmission date: October 7th, 2014

ANAMNESIS (October 17th, 2014)The patient was admitted to Neurology ward Moh.Hoesin General Hospital because decreased of consciousness gradually.+ 4 months before admitted to the hospital, the patient had persistent headache, cough, mucous (+), blood (-). He had fever, loss of appetite, sweat in night, and loss of body weight, nausea and vomiting. + 3 months before admitted to the hospital, the patient had admitted to Sekayu hospital because he had feel weakness of his body, and the doctor said that he got lung disease. Then he got the medicines and after around 1 week he feels better, then he stopped to drink medicine and he did not control to hospital. At home, he drunk drugs regularly, but he stopped. + 2 days before admitted to the hospital, the patient had decreased of consciousness gradually, such as anxious and disorientation. He had headache, nausea and vomiting, no seizures, no hemiparese. He had no history of ear infections, no history of seizures, no history of diabetes, no head trauma. The patient suffered this illness for the first time.

PHYSICAL EXAMINATION (October 17th, 2014)PRESENT STATEInternal State Sense:E3M5V3 Nutrition: SufficientTemperature : 38.9 oCPulse : 90 beats/minRespiratory rate : 20 times/minBlood pressure : 130/100 mmHgHeart : No abnormalityLungs: Inspection : Static and Dinamis, left chest : left behind

Psychiatric stateAttitude : Not yet assessed Attention : Not yet assessed

Neurological stateHead Shape: BrachiocephalySize : NormalSymetric: YesHematome: NoTumor: NoNeck Position : StraightTorticolis: NoNape of neck stiffness: YesPalpation : stem fremitus of left chest decreasedPercussion : hipersonor in left chestAuscultation: vesicular in left chest decreasedLiver : No abnormalitySpleen : No abnormalityExtremities :See neurological stateGenital : No abnormality

Facial Expression : Not yet assessedPsychology contact: Not yet assessed

Deformity: NoFracture: NoFracture pain: NoVessel: No wideningPulsation: No disorder

Deformity: NoTumor: NoVessels: No widening

CRANIAL NERVESN.I: Olfaktorius nerveSmellingAnosmiaHyposmiaParosmia

N.II: Opticus nerveVisual acuityCampus visi

Anopsia Hemianopsia

Oculi fundus Edema papil Atrophy papil Retina bleeding

N.III: Occulomotorius, N.IV: Trochlearis, and N.VI: Abducens nerves DiplopiaEyes gapPtosisEyes position Strabismus Exophtalmus Enophtalmus Deviation conjugaeEyes movementPupil Shape Size Isochor/anisochor Midriasis/miosisLight reflex direct consensuil accommodationArgyl Robertson

N.V: Trigeminus nerveMotoric Biting Trismus Corneal reflexSensory Forehead Cheek Chin

N.VII: Facialis nerveMotoricFrowningEyes closingGigglingNasolabial foldFacial shape rest Speaking/whistlingSensory 2/3 anterior tounge

Autonomy Salivation Lacrimation Chvosteks sign

N.VIII: Statoacusticus nerveCochlearis nerveWhisperingHour tickingWeber testRinne testVestibularis nerveNystagmusVertigo

N.IX: Glossopharyngeus, and N.X: Vagus nervesPharyngeal archUvulaSwallowing disorderHoarsing/nasalisingHeart beatReflex Vomiting Coughing Occulocardiac Caroticus sinusSensory 1/3 posterior toungeRightNot yet assessed Not yet assessed Not yet assessed Not yet assessed

RightNot yet assessedV.O.D

Not yet assessedNot yet assessed

NoNoNo

RightNot yet assessedNoNo

NoNoNoNo Not yet assessed

Round 3mmIsochorNo

PositivePositive PositiveNo

RightNot yet assessedNot yet assessedNot yet assessed

Not yet assessedNot yet assessedNot yet assessed

RightNot yet assessedNormal NormalNormal

No disorderNot yet assessed

Not yet assessed

No disorderNo disorderNo disorder

RightNot yet assessedNot yet assessedNot yet assessedNot yet assessed


RightNot yet assessedNot yet assessedNot yet assessedNot yet assessedNormal

No disorderNo disorderNo disorderNo disorder

Not yet assessed

LeftNot yet assessed Not yet assessed Not yet assessed Not yet assessed

LeftNot yet assessedV.O.S


NoNoNo

LeftNot yet assessedNoNo

NoNoNoNo Not yet assessed

Round 3mmIsochorNo

PositivePositivePositiveNo

LeftNot yet assessedNot yet assessedNot yet assessed

Not yet assessedNot yet assessedNot yet assessed

LeftNot yet assessedNormal Angle paralysis Flat

No disorderNot yet assessed

Not yet assessed

No disorder No disorderNo disorder

LeftNot yet assessedNot yet assessedNot yet assessedNot yet assessed


LeftNot yet assessedNot yet assessedNot yet assessedNot yet assessedNormal

No disorderNo disorderNo disorderNo disorder

Not yet assessed

N.XI: Accessorius NerveShoulder RaisingHead Twisting

N.XII: Hypoglossus NerveTounge ShowingFasciculationPapil AthrophyDysarthria

MOTORICArmsMotionPowerTonesPhysiological Reflex Biceps Triceps Radius UlnaPathological Reflex Hoffman Tromner Leri Meyer Trofik

LEGMotionPowerTonesClonus Tigh Foot Physiological reflex K P R A P RPathological reflex Babinsky Chaddock Oppenheim Gordon Schaeffer Rossolimo Mendel BechterewAbdominal skin reflex Upper Middle Lower Tropik RightNot yet assessedNot yet assessed

RightNot yet assessedNot yet assessedNoNot yet assessed

RightLateralization to Left sideLateralization to Left sideNormal

NormalNormalNormalNormal

NegativeNegativeNegativeNegative

RightLateralization to Left sideLateralization to Left sideNormal

Negative Negative

Normal Normal

NegativeNegativeNegativeNegativeNegativeNegativeNegative


LeftNot yet assessedNot yet assessed

LeftNot yet assessedNot yet assessedNoNot yet assessed

Left

Increase

IncreaseIncreaseIncreaseIncrease


Left

Increase

PositivePositive

IncreaseIncrease

PositivePositiveNegativeNegativeNegativeNegativeNegative


SENSORYNot yet assessedPICTURE

VERTEBRAL COLUMNKyphosis: No Tumor: NoLordosis: No Meningocele: NoGibbus: No Hematome: NoDeformity: No Tenderness: No

SYMPTOMS OF MENINGEAL IRRITATIONNape of neck stiffnessKerniqLassequeBrudzinsky Neck Cheek Symphisis Leg I Leg IIRightYesNoNo

NoNoNoNoNoLeftYesYesYes

NoNoNoNoNo

GAIT AND EQUILIBIRIUMGaitEquilibirium and CoordinationAtaxia: Not yet assessedRomberg: Not yet assessedHemiplegic: Not yet assessedDysmetri: Not yet assessedScissor: Not yet assessedfinger finger: Not yet assessedPropulsion: Not yet assessedfinger nose: Not yet assessedHisteric: Not yet assessedheel - heel: Not yet assessedLimping: Not yet assessedReboundphenomenon : Not yet assessedSteppage: Not yet assessedDysdiadochokinesis: Not yet assessedAstasia-Abasia: Not yet assessedTrunk Ataxia: Not yet assessedLimb Ataxia: Not yet assessed

MOTION ABNORMALTremor: NoChorea: NoAthetosis: NoBallismus: NoDystoni: NoMyoclonus: No

VEGETATIVE FUNCTIONMicturition: Urine CatheterDefecation: No abnormalityErection: Not yet assessed

LIMBIC FUNCTIONMotoric aphasia: Not yet assessedSensoric aphasia: Not yet assessedApraksia: Not yet assessedAgraphia: Not yet assessedAlexia: Not yet assessedNominal aphasia: Not yet assessed

LABORATORY FINDINGSBLOOD (7th October 2014)Hb: 11.7 gr/dl (12-16)Erythrocyte: 4.41 ml/mm3 (4.0-5.0)Hematocrit: 33 vol% (37-43 vol%)Leucocyte: 13300/mm3 (5000-10000)LED: 120mm/hour ( 200)Cloride : 118 mEq/L (98-107)

CULTURE CSF (9th October 2014)Bacteria: Staphylococcus epidermidisMicroscopic: gram (+), coccus (+), leukosit 0-4/lp, epitel 0-1/lpAntibiotic: Amikacin sensitive

CULTUR BTA (13th October 2014)BTA 1,2,3 sputum: positive (3+)BTA from CSF: negativeSPECIFIC EXAMINATIONCranium X- Ray: Not performedChest X- Ray: Pulmonary Tuberculosis and pneumothorax

Vertebral column X- Ray: Not performedElectroencephalography: Not performedElectroneuromyography: Not performedElectrocardiography: Not performedArteriography: Not performed Pneumography: Not performedHead CT-Scan: Not performed

RESUMEIDENTIFICATIONMr. AM, male, 25 years old, admission date 7th October 2014ANAMNESISThe patient was admitted to Neurology ward RSMH because decreased of consciousness gradually.+ 4 months before admitted to the hospital, the patient had persistent headache, cough, mucous (+), blood (-). He had fever, loss of appetite, sweat in night, and loss of body weight, nausea and vomiting. + 3 months before admitted to the hospital, the patient had admitted to Sekayu hospital because he had feel weakness of his body, and the doctor said that he got lung disease. Then he got the medicines and after around 1 week he feels better, then he stopped to drink medicine and he did not control to hospital. At home, he drunk drugs regularly, but he stopped. + 2 days before admitted to the hospital, the patient had decreased of consciousness gradually, such as anxious and disorientation. He had headache, nausea and vomiting, no seizures, no hemiparese. He had no history of ear infections, no history of seizures, no history of diabetes, no head trauma.The patient suffered from this illness for the first time.

EXAMINATIONPresent StateSense: E3M5V3Nutrition: SufficientTemperature : 38.9 oCPulse : 90 beats/minRespiratory rate: 20 times/minBlood pressure : 130/100 mmHg

Neurological stateNn. CranialesN. VII: Left angle paralysis of mouth, and flat nasolabial fold.

Motoric functionMotoric functionArmLeg

RightLeftRightLeft

Motion Lateralization to Left side

Power Lateralization to Left side

Tones NN

Clonus-+

Physiological reflexNN

Pathological reflex---+B,C

Sensory function: Not yet assessedLimbic function: Not yet assessedVegetative function : Not yet assessedMeningeal Irritation: Positive (Nape of neck stiffness, Kerniq, Lasseque)Abnormal Movement: Negative Gait & Stability: Not yet assessed

LABORATORY FINDINGSBLOOD (7th October 2014)Hb: 11.7 gr/dl (12-16)Hematocrit: 33 vol% (37-43 vol%)Leucocyte: 13300/mm3 (5000-10000)LED: 120mm/hour ( 1,016)Clot : negativepH: 9.0 (transudate: 7,4-7,6; exudate: < 7,3)MicroscopicLeukosit : 11,0 sel/l (transudate: < 500; exudate: > 500)Diff.count PMN cell : 18% (transudate: less; exudate: more)MN cell : 82% ((transudate: more; exudate: less)Nonne : negativePandy : positiveProtein: 0,3 g/dL (transudate: < 2,5; exudate: > 3)Glucose: 41,7 gr/dL (transudate: same in serum; exudate: < in serum)LDH : 99 U/L (transudate: < 200; exudate: > 200)Cloride : 118 mEq/L (98-107)

CULTURE CSF (9th October 2014)Bacteria: Staphylococcus epidermidisMicroscopic: gram (+), coccus (+), leukosit 0-4/lp, epitel 0-1/lpAntibiotic: Amikacin sensitive

CULTUR BTA (13th October 2014)BTA 1,2,3 sputum: positive (3+)BTA from CSF : negative

SPECIFIC EXAMINATIONChest X- Ray: Pulmonary Tuberculosis and pneumothorax

DIAGNOSISClinical Diagnosis: Hemiparese sinistra spastic + parese N VII sinistra central type + Meningeal Irritation Topic Diagnosis: Meningen, encephalonEtiologic Diagnosis: Tuberculous MeningoencephalitisAdditional Diagnosis: Pulmonary Tuberculosis + pneumothorax post WSD

MANAGEMENTIVFD NaCl 0,9% gtt XXX/mDexamethasone 3 x 1 mg IVRanitidin 2 x 50 mg IVATD: Rifampicin 1x450 mg PO Isoniazid 1x300 mg PO Pirazinamid 1x1000 mg PO Etambutol 1x75 mg POParacetamol 3x1000 mg IVO2 6-8 liters/m NRMCatheter urineLiquid diet 1800 kkal PROGNOSISQuo ad vitam : DubiaQuo ad functionam : DubiaCASE ANALYSIS

Differential diagnosis

Tuberculous Meningoencephalitis Symptoms of the patient were:

History : cough with mucous and blood, fever, loss of appetite, sweat in the night, loss of body weight+ 4 months: persistent headache, cough, mucous (+), blood (-), fever, loss of appetite and body weight, sweat in night.

Decreased of consciousness which happened graduallyThe patient was admitted to Neurology ward RSMH because decreased of consciousness which happened slowly.

Cranial nerves are involved N. VII: Left angle paralysis of mouth, and flat nasolabial fold.

GRMPresent

Chest X-ray, SputumPulmonary Tuberculosis, BTA 1,2,3 (+)

CSFTuberculous Meningoenchepalitis

So the possible diagnose of Tuberculous Meningoencephalitis can be fulfilled

Bacterial Meningoencephalitis Symptoms of the patient were:

Manifestation: fever, headache, photofobia, seizure.Fever, headache were present, but photofobia and seizure were not found.

History of extra cranial infection, such as otitis, sinusitisNo found

Decreased of consciousness which happened graduallyThe patient was admitted to Neurology ward RSMH because decreased of consciousness which happened gradually.

Cranial nerves are involved N. VII: Left angle paralysis of mouth, and flat nasolabial fold.

GRMPresent

CSF CultureStaphylococcus epidermidis

There is possible possibility of Bacterial Meningoencephalitis

SAHSymptoms of the patient were:

Persistent Headache+ 4 months: persistent headache

SeizureNo history of seizure

Head trauma history or hypertension historyNo history of head trauma or hypertension

Eye disorderNo present

There is no possibility of SAH1

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Meningoencephalitis TB