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Explain the diagnosis management history of present illness medication advise and plan of treatment spinal tenderness pupils examination

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Complete Clinical Summary - Meena Kanwar

Patient Details

Name: Meena Kanwar, W/O Kuldeep Singh Kanwar
Age/Gender: 35 years / Female
CR No.: 921512600308749
Hospital: Atal Institute of Medical Super Specialities (AIMS), Shimla, Himachal Pradesh
Department: Neurology - Unit 1
Consultant: Dr. Ranjot Kaur (Asst. Professor, Neurology) / Dr. Sudhir Sharma
Date of Presentation: 01 July 2026

History of Present Illness (HPI)

Chief Complaint: Headache - approximately 1 month history
Onset to peak: 1 to 1.5 hours
History of fever: 1 month back, lasted 4-5 days, now resolved
Red flag signs present:
- Daily headache (chronic, not episodic)
- Postural variation - significant; mild relief on lying down, worsens on standing
- Headache increases on coughing / Valsalva maneuver
Associated symptoms: Headache with vomiting (noted on 2 July 2026 progress note)
No burning micturition
Cough: +/- (mild/intermittent)
No prior h/o similar headaches

Physical Examination

General

BP: 108-110/70-80 mmHg
Weight: 50 kg
Pulse Rate: 80-105/min
Autonomic features: Negative
Fever: Presently none at admission; later recorded 100.3°F on 3 July 2026
Per abdominal & rectal exam: Normal

Nervous System Examination

Finding	Result
Neck rigidity	Negative (absent)
Spinal tenderness	Positive (+)
Extraocular movements (EOM)	Normal
Pupils	Bilateral equal and reactive to light (B/L Equal & RTL)
Plantar reflex (Right)	Downgoing (flexor = normal)
Plantar reflex (Left)	Downgoing (flexor = normal)

Pupils: Both pupils were equal in size and showed normal, brisk reaction to light - no anisocoria, no RAPD, ruling out herniation, CN III palsy, or raised ICP at the time of initial examination.

Spinal tenderness: Present - this was a key finding pointing toward spinal involvement, supporting the need for MRI Spine and later CSF analysis.

Investigations

Initial (OPD - 1 July 2026)

Investigation	Result
NCCT Head	Normal
Fundus examination	No raised intracranial tension
ENT evaluation (IGMC)	Normal

Subsequent (Inpatient)

MRI Brain with contrast (P+C): Done (3 July 2026)
MRI Spine screen: Planned/Done
CBC, RFT, LFT, Electrolytes, ESR, CRP: Advised
Chest X-ray (PA view): Advised
CSF Analysis (Lumbar Puncture - 5 July 2026 6:30 PM):
- Around 1 mL CSF drained
- Opening pressure: 10 cmH₂O (low - confirms intracranial hypotension)
- Straw/xanthochromic appearance noted ("sero portion only")
- Concomitant RBS: 114 mg/dL

Diagnosis

Initial (1 July 2026 - OPD)

? Migraine without aura
? Low CSF pressure headache (Spontaneous Intracranial Hypotension / SIH)

Revised Provisional Diagnosis (Inpatient)

New onset headache with postural variation - rule out SIH

Final Confirmed Diagnosis

Tubercular Meningoencephalitis (confirmed after MRI Brain + Contrast, CSF analysis, and clinical evolution)
TB Notification Number issued: 2956489753 - IGMC Shimla, dated 4 July 2026

Disease Evolution / Progress

Date	Key Events
1 Jul 2026	OPD visit; headache 1 month history; provisional: migraine / low CSF pressure; admitted to neurology ward
2 Jul 2026	BP 100/70, PR 80/min; c/o headache + vomiting; new acute headache with postural variation; IV NS @ 100 ml/hr started
3 Jul 2026	Received post-MRI; fever 100.3°F; altered behaviour; increased headache; plantars bilaterally upgoing (extensor - new finding indicating upper motor neuron involvement); MRI Brain + Contrast done; plan: CSF analysis, CBC/RFT/LFT/ESR/CRP
4 Jul 2026	Consultant review: Dexamethasone stat + TDS; ATT 3-drug FDC started stat; discharge summary drafted: "35 yr female with headache, MRI shows tuberculoma, hence start ATT"; TB notified
5 Jul 2026	LP done at 6:30 PM; opening pressure 10 cmH₂O; CSF sent; BP 112/60, PR 105/min

Medications & Treatment Plan

Acute/IV Treatment

Drug	Dose	Route	Frequency
Inj. Dexamethasone (Dexa)	6 mg	IV	Stat, then TDS (3x/day)
Inj. IVF Normal Saline	100 mL/hour	IV	Continuous
Inj. Diclofenac	Standard dose	IV (in NS)	As per chart
Inj. Rantac (Ranitidine)	40 mg	IV	Twice daily (BD)
Inj. Phenergan (Promethazine)	Standard	IV	Twice daily (BD)

Anti-Tubercular Therapy (ATT)

ATT 4-Drug FDC (Fixed Dose Combination) under DOTS (Directly Observed Treatment Short-course)
Initial consultant note: 3-drug FDC stat (likely pre-full-ATT empirical start)
Escalated to 4-drug FDC - standard TB regimen (Isoniazid + Rifampicin + Pyrazinamide + Ethambutol)

Oral Medications

Drug	Dose	Frequency	Purpose
Tab. Dolo Xtra (Paracetamol + Caffeine)	650 mg	BD / SOS	Pain relief, headache
Tab. Amitop (Amitriptyline)	10 mg	HS (at bedtime)	Headache prophylaxis
Tab. Calcimax	500 mg	OD	Calcium supplementation
D3 Nano/Wave Shots	60,000 IU	Once weekly x 8 weeks	Vitamin D deficiency
Tab. Pyridoxine (B6)	20 mg	OD	Prevent INH-induced neuropathy

Monitoring

Temperature charting every 6 hours
Input/Output (I/O) charting
BP and PR monitoring

Plan at Discharge (5 July 2026)

Discharge planned for Monday/Sunday
Continue ATT 4-FDC under DOTS
KFT / LFT / Electrolytes repeat
MRI report follow-up
TB Notification completed (mandatory reporting done)

Clinical Summary & Explanation

This 35-year-old woman initially presented with what appeared to be low CSF pressure headache or migraine - postural headache worse on standing, better on lying down. However, the combination of:

Prior fever (suggesting infection)
Postural headache with daily occurrence
Worsening course with fever (100.3°F), altered behaviour, and bilateral extensor plantars (new UMN sign)
MRI Brain showing tuberculoma
Low opening pressure on LP (10 cmH₂O)

...led to the diagnosis of Tubercular Meningoencephalitis. The spinal tenderness on examination was consistent with spinal TB involvement or meningeal irritation extending to the spine. The initially normal neck rigidity does not exclude TBM, as it can be absent early. Dexamethasone was started to reduce the inflammatory response around tuberculomas (proven to reduce mortality/morbidity in TBM), alongside immediate ATT initiation.

Important Note: The information above is extracted from the clinical documents as a summary to aid understanding. All treatment decisions should remain under the supervision of the treating neurologists (Dr. Ranjot Kaur, Dr. Sudhir Sharma) at AIMS Shimla.

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