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MLC Jehanbanu 45F
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Here is a summary of what was compiled into the MLC document:
MLC SUMMARY — JEHANBANU, 45 Y/F
Referred from: Nirman Hospital
Alleged History / Reason for Referral:
- Admitted at Nirman Hospital (15/04/2026 – 25/04/2026) with Meningoencephalitis (Blood C/S positive) and Tuberculous Meningitis (CSF ADA = 27); CSF tapping performed there.
- Additional alleged H/O RTA (motor vehicle accident, 6:00 AM, 04/01/2026) with left eye injury.
Presenting Complaints:
- Altered sensorium (reduced responsiveness) — onset 10 PM night prior (patient was asymptomatic before)
- Low grade fever without chills/rigors — 2 days
- Weight loss ~2–3 kg — last 2–3 months
- Headache — 15 days
- 8–10 episodes of vomiting — 10 days ago
Outside Investigations (Nirman Hospital):
| CBC | Hb 8.9 / TLC 12.3 / Plt 77 |
| CSF Protein | 353 mg/dL |
| CSF Glucose | 22 mg/dL |
| CSF TC | 800 cells (Poly:Lympho = 90:30) |
| CSF ADA | 27 U/L |
| CSF GenXpert | Negative |
| CRP | 106 |
| Peripheral smear | Poikilocytosis, Anisocytosis |
| Repeat CBC (23/4) | Hb 7.6 / TLC 188 / Plt 193 |
| K / Na | 2.94 / 131 mEq/L |
Vitals on Admission:
- T: 100.5°F | P: 90/min | RR: 28/min (gasping) | BP: 122/70 mmHg
- SpO₂: 50% RA → 77–100% on ventilator
CNS: GCS E1V1M1 — Intubated; Plantar B/L Flexor; Tone 1/6
Provisional Diagnosis: Tuberculous Meningitis | Meningoencephalitis | Anaemia | Hypokalaemia | Hyponatraemia | H/O RTA with left eye injury
Note: Some handwriting in the images was partially illegible (notably the right-side vitals column in image 2 and some abbreviations). Please review and correct any entries before official submission.
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