42 years old male patients with chief complaints of fever and headache since 5 days

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Date of admission:9/12/22

Chief complaints:

42 years old male patients with chief complaints of fever and headache since 5 days

History of present illness:

Patient was apparently asymptomatic 5 days back then he developed fever of low grade which reduced on taking medication

Fever was associated with headache which was pricking type.

Patient was diagnosed with renal failure

History of past illness:

Patient is a k/c/o hypertension since 1 year and is on regular medication

Patient is not a k/c/o diabetes, epilepsy, asthma, cad

Family history:

Patient mother had hypertension

Personal history:-

Occupation-daily wage labourer

Diet- mixed 

Apetite- lost

Sleep-disturbed

Bowel movements- normal 

Addictions-alcohol consumption and beedi daily 1 pack since 15years of age

General examination:-

Patient is conscious, coherent, cooperative,well oriented to time, place and person. 

No sign of pallor, icterus, clubbing, cyanosis, 

Generalized lymphedenopathy

Vitals:-

Temp- 98 F 

Bp-160/100mm hg

PR- 76pm

RR-16cpm

Systemic examination:-

Cvs-S1 S2 heard, no murmurs heard

RS- bae+ ,normal vesicular breath sounds

Abdomen-scaphoid, liver spleen not palpable

CNS:Conscious,

Slurred speech

Signs of meningeal irritation-

Neck stiffness is present

Kernigs sign absent

Tone of upper limbs is normal, Hypertonia in right lower limb

Power upper limbs right 5/5 and left - 5/5 and lower right limb 4+/5 lower left limb - 4+/5

Cranial nerves intact

Reflexes: 

RIGHT: Biceps +3

Triceps+3

Supinator+2

Knees+3

Ankle+2

LEFT: Biceps +2

Triceps +2

Supinator +2

Knees +2

Ankle +1

Cerebellar signs:

Finger to nose coordination is absent

Clinical images

Investigations:

Provisional diagnosis:

AKI 

?meningitis

Treatment:

IVF ns 50ml/hr

Tab cinod 10mg po