Things not to miss - DVT

A young female patient admitted with a one week history of headache and low grade fever. She has had on and off headache for 2 weeks prior to the onset of headache. On examination she had neck stiffness and papilloedema. Patient had diplopia towards right side.

CSF study was done

Appearance - clear
Opening Pressure - normal
Cell count - 80 (70% lymphocytes, 30% neutrophils)
Protein - 120mg/dl
Sugar - 34mg/dl (Blood sugar 88mg/dl)
AFB - Not seen
Culture - No growth

She was started on anti TB treatment as the most likely diagnosis was TB meningitis.

6 days into illness her headache was slightly reduced. Fever was still there, but the patient was feeling relatively better. She was spent most of her time on bed as she found it difficult to walk due to diplopia.

On day 10 after admission she complained of sudden onset shortness of breath. There was tachycardia. Saturation was 89% on air. Lungs were clear to auscultation. Her left leg was swollen and tender. When she was asked about the swelling she told, 'doc, I had it for the last two three days. I didn't tell you because it didn't hurt much!'

Diagnosis - Pulmonary embolism!

Lesson

Never forget DVT prophylaxis in patients who are not mobilized. 

Make it a habit to have a look at the legs of each and every patient during ward rounds. DVT, Cellulitis are things that you often will miss.

Homework!

What are the differential diagnosis for this patient other than TB meningitis?? 


What are the risk factors for TB meningitis?

What are the ways available to confirm the diagnosis of TB meningitis?

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