GENERAL INFORMATION

Name: Maria Valentina Ivanovna

Sex: female
Age: 33 Years (07/11/77)
Profession: engineer
Address: Moscow Leninsky prospect
Admitted time and Date: 13:02 (24/12/10)
Transport: Wheel chair
Diagnosis by polyclinic doctor: Acute Senorineural Hearing Loss
Diagnosis at the time of admission: Acute SNHL (Date: 24/12/10)
Clinical diagnosis: Acute SNHL due to bacterial meningitis (Date: 25/12/10)

Main diagnosis:
Bacterial Meningitis.
Complication: Bilateral Acute SNHL.

COMPLAINS AT THE TIME OF ADMISSION

She complains of total loss of hearing from both ear.

ANAMENESIS MORBI

According to words of patient she had this problem since last two weeks. She has
been hearing less in her left ear for last 2 weeks or so. She has been suffering from
neck rigidity and high fever. After consultation with therapist and
otorhinolaryngologist she was advised to admit to hospital. She ignored their advice,
but in the last 2 days or so she has stopped hearing from both her ear fully.

ANAMENESIS VITAE

Childhood diseases: Common cold. She had Pneumonia when she was 21 years old.
Operations: none
Traumas: no major traumas in life
Living conditions: There the living condition is good. She is married and has one son.
She is living in a middle class family in Moscow.
Working conditions: She works as an engineer. Her working conditions are good.
Harmful habits: Smokes 2 cigarettes per day. She drinks occasionally.
Allergic Anamnesis: She has no allergy.
Familial diseases: Mother- Hypertension, Father – Diabetes Mellitus II type,
Grand mother (60) died of stroke (was hypertensive).
There was no syphilis or neurological diseases in her family.

STATUS PRESENS

General State: Good

Consciousness: Clear
Position of the patient: active
Height 163 cm
Weight 57 kg
 B.M.I, is 21.5
Blood Pressure 120/80 mm Hg.
Breathing rate – 14/min
Her body temperature is normal and it is 37’C
Skin and mucosa: Her skin is normal. Nails are without clubbing and they look
normal. Mucosa is normal without presence of any cyanosis.
Subcutaneous fatty tissue: It is moderately developed. There is no edema of the feet.
Lymphatic system: It is normal and there is no enlargement of lymph nodes.
Muscular system: It has no pathology. No abnormality on palpation. Tonicity is
normal and there is no atrophy.
Bones: She has no pain in bones. Curvature is normal for his age, terminal fingers are
normal.
Joints: She had no pain in joints and it is normal.

RESPIRATORY ORGANS
Complains: There is no complains. She has no dyspnea. No pathological changes in
the respiratory system
Examination: Nasal passages are free. There is no nasal bleedings. Her voice is
normal. In the thorax the anterior posterior diameter is lesser than the lateral diameter
showing no emphysema. Supra and subclavial spaces, intercoastal space, epigastric
angle are almost symmetrical there is no lordosis, kyphosis or scoliosis of the spine.
Respiration: Frequency 20/ min. It is not rhythmical. Auxiliary muscles are
participating in the respiratory movement.
Palpation of thorax: There is no pain while palpation. Resistance of the thorax is
good. Fremitus vocalis is symmetrical in both the lung.
Percussion: The relative percussion is same in the both lungs and it is normal.
Topographic percussion: Apex and inferior borders of lungs are normal. Apex is 4 cm
above the superior thoracic opening. Lower border of both lungs are as follows:

Right lung Left lung On line

6 rib Mamillary line
7 rib 7 rib Axillary anterior line
8 rib 8 rib Axillary middle line
9 rib 9 rib Axillary posterior line

10 rib 10 rib Scapular line

11 rib 11 rib Spine
Auscultation: We here normal breathing which is vesicular without any crepetation.

CIRCULATORY ORGANS
Examination: Pulsation in the carotid region is normal. The localization of the apical
beat is 1cm medial of the mid clavicular line showing no left ventricular hypertrophy.
Palpation: The apical beat is medial to mamillary line, its force is normal. There is no
pathological pulsation in the region of the heart (systolic or diastolic murmer)
Percussion: The right border of the heart is 1 cm laterally from the parastemal line.
The left border - 1cm medial to the mammilary line. The upper border - 2nd
intercoastal space.
Auscultation: 1st point’s sound on the apex of heart is normal. 2nd point’s sound at
the right 2nd intercoastal space of sternum is also normal 3rd point’s sound at the left
2nd intercoastal space of sternum is normal without galloping. 4th Point’s sound at
the inferior third of the sternum is normal. There is no sound of aortic regurgitation at
botkin’s point.
Murmer: No munners are heard.
Pericardial knock: No pericardial knock is heard.
Examination of vessels: Palpation of the radial, carotid, and femoral and the arteries
of the leg are soft and normal. Auscultation of abdominal, femoral, renal arteries is
normal. Radial artery pulse on the right and left hand are symmetrical. Frequency is
60/min. It’s rhythmic and the filling is low. Pulse is normal, regular.
We cannot see distention of venous vein in sitting position showing no right
ventricular failure.

DIGESTIVE ORGANS
Complains: There is no abdominal pain, no heartburns. There is no appetite disorder
or dryness or bitter taste in the mouth. No difficulty in passing the food through the
esophagus. There is no constipation or diarrhea. Stool mass and. color is normal
without blood or fat in it.
Examination of oral cavity: She has normal teeth. Her gums are normal too. Tongue
and tonsils are normal pink colour.
Examination of the abdomen: There is no ascities. The abdominal wall is taking part
in respiration. There are no subcutaneous veins seen on the abdomen (no portal
hypertension), no out pouching in umbilical region. No hernia at linea alba.
Percussion: We hear normal tympanic sound.
Palpation: By superficial palpation we see that the tension of the abdominal wall its
morbid and muscular tonicity is normal.
Deep methodical slipping palpation: Sigmoid colon, caecum, transverse colon are
normal. Small and large intestine are normal.
Auscultation of the stomach: We can hear normal peristalsis.
LIVER
Complains: She has no complains from the liver.
Examination: There is no bulging of the liver.
Percussion: Superior border is at 5th inter coastal space .The
Inferior border is normal showing no enlargement of the Liver.
The Kurlov's dimension of the liver is 9 / 8 / 7 (normal)
Palpation: The inferior border of the liver is not palpable. Surface of liver seems
normal without any nodules. At deep palpation the gall bladder is normal.
SPLEEN
Percussion: 4х6 cm and diameter is 3 cm, and it is normal in size.
Palpation: Spleen is normal in size so not well palpated. Its consistence was normal
and soft.
UROGENITAL SYSTEM
Complains: She has no pain in the region of the lions, or at kidney the pathways
ureter, urinary bladder, urethra are normal. There is no blood or pus in the urine.
Palpation: There is no enlargement and no pain; Pastemaskiy's syndrome is negative.
Percussion and palpation of the urinary bladder shows that they are normal.
ENDOCRINE SYSTEM
On palpation of the thyroid gland they are normal. She has no endocrine disease.
NEURO-PSHYCOLOGICAL INDEX AND SENSORY ORGANS
Complains: She has been suffering from neck rigidity.
Intellect: Normal. She has free contact.
The memory: Normal. Orientation to the time and environment is normal for her age.
She knows the reality of the illness. Muscle tone is normal. Vision is normal.
Audition is decreased in the left ear. She says that he can taste normally.
Meningeal symptoms: positive for all meningeal symptoms.
Kernig’s symptom- positive
Upper, middle and lower Brudzinsky symptom- positive
Pathological Babinsky reflex- present.

E.N.T. STATUS (Status localis)

Nose: form of nose is normal. Skin of nose also normal. Nasal passages are free.
Mucous membrane of nasal cavity normal. Nasal discharge is not present.
Nasal septum: is at middle line in location.
Palpation of maxillary sinus is painless.

Pharynx: Oropharynx is not stretched, soft palate is symmetrical. Palatine tonsils are
not enlarged and not hyperemic. No infiltration of posterior wall of pharynx.
Nasopharynx: is normal without any pathology.
Laryngopharynx: there is no enlargement of lingual tonsils.

Larynx: No changes in the voice, no deformation is seen. All cartilages of larynx are
normal in shape and position.
Vocal cord is white and movable; distance between two vocal membranes is 10mm.
Sub vocal folds are free.
GENERAL EAR EXAMINATION:
Right ear Left ear
Auricle Pale pink same as colour Pale pink same as colour
of skin, non inflammed of skin, non inflammed
Periauricular region Pale pink same as colour Pale pink same as colour
of skin, non inflammed of skin, non inflammed
Ext.Ac.Meatus Wider and free Wider and free
Tympanic membrane Colour is pale and silver, Colour is pale and silver,
Triangular conus of light Triangular conus of light
present with distinct present with distinct
borders borders
INVESTIGATION OF HEARING AT TIME OF ATTACK:
Right ear Left ear
Cannot hear Subjective sounds Cannot hear
Cannot hear Whispering Cannot hear
Cannot hear Articular speech Cannot hear
Tuning forks - C 128 and C 2048 were used for the tests respectively
Rinna’s test – Air conduction is less than bone conduction.
Webers probe – Lateralization to the right side.
INVESTIGATION OF VESTIBULAR APPARATUS:
Romberg’s position- Patient falls down.
Flang’s step – negative on both sides
Front steps – negative on both sides
Adiadochokinesis- negative on both sides
Caloric test – negative on both sides
Somatic reaction: patient falls down
Vegetative reaction: Patient turns pale, pulse decreases, cold sweat, nausea.
Nystagmus appears, which stays for 2 minutes.
Pneumatic probe – negative on both sides
Oteolith method – Patient falls down, Pale skin, decreased pulse, cold sweat, nausea,
vomiting.

PRELIMINARY DIAGNOSIS
Bacterial meningitis.

PATIENTS EXAMINATION PLAN

General and Biochemical analysis of blood, urine, Pure tone audiometry, Speech
audiometry, Dehydration test.

DATA OF INVESTIGATION

General blood analysis: (25/12/10)

Blood elements Patient’s data (Results) Norm & Units
Red blood cells 4.12 4.0-5.0 M/µ l
Leukocytes 14.0 4.0-9.0 K/µ l
Hb 160 130.0-160.0 g/liter
ESR 5 2-10 mm/hour
Segmented Neutrophills 78 47.0-80.0 %
Eosinophils 1 0.5-1 %
Basophils 2 0.000-2.000 %
Lymphocyte 16 19.0-37.0 %
Monocyte 3 0.00-11.00 %
Thrombocytes 174 140-440 K/µ l
Hematocrit 46 40.0-48 %
Biochemical analysis of blood: (25/12/10)
Data RESULT Normal
AST 21.5 10-50
ALT 24 10-40
LDH 335 226-451
CPK 35.06 0-4
UREA 7.4 1.7-8.3
BILIRUBIN 10 8.5-24.5
CHOLESTEROL 3.7 3.6-6.8
GLUCOSE 3.5 3.33-5.55

Analysis of urine: (25/12/10)

DATA RESULT NORMAL
COLOR Normal -
TRANSPARENT Normal
PROTEIN 0.165 -
DENSITY 1026 1018-1030
REACTION Acidic -
GLUCOSE Absent -
KETONE BODIES Absent -

Lumbar puncture: elevated CSF pressure(40cm H2O)

Cloudy appearance of CSF(proving high level of protein, WBC
and bacteria.
Gram-stain proves present of Meningococci.
Pure tone audiometry (25/12/10): Sensory neural hearing loss where both air
conduction and bone conduction are absent.

FINAL DIAGNOSIS: Bacterial Meningitis followed by bilateral Acute Sensorineural

Hearing Loss.

BASIS OF THE DIAGNOSIS

Complains: The patient says that she has been suffering nural rigidity, high fever and
hearing loss in both ears. The triad of symptoms for meningitis is present.
Examination of the Auditory Apparatus: Shows inflammation of the labyrinth.
Pure tone audiometry: Sensory neural hearing loss.
Lumbar Puncture: Shows elevated CSF pressure.
Bacteriological Investigation: proves presence of Meningococci in CSF.

TREATMENT: Conservative treatment

General reccomendations: Bed rest, Avoid excessive movement and physical activity
Quit smoking, Decrease caffeine, alcohol use, Low salt diet.
Training exercises and Physiotherapy
Medications: anti-bacterial: Cefotaxime.
Vancomycin
Cortico-steroid: Dexamethasone
DIARY:
24-12-2010
The patient complains of total hearing loss in both ears. Her general condition is not
good. After performing audiogram it was found that she cannot hear in both ears.
25-12-2010
The patient still complains of hearing loss. General condition is not good. Treatment
was started on preliminary diagnosis of bacterial meningitis. Audiogram shows no
improvement yet.
27-12-2010
The patient’s condition was not good. She has headache, vertigo, loses her balance
when she stands.
BP- 120/80 mm of Hg
Body temperature was 36.5C.
28-12-2010
The patient’s condition improves up to some extent. The treatment helps patient in
relief from vertigo. Hearing is mild.
BP- 130/85 mm of Hg.
Body temperature was 36.7C
29-12-2010
The patient is feeling better. Hearing is normal. She is capable of doing mild physical
work.
BP- 130/90 mm of Hg
Body temperature 36.7C
31-12-2010
The patient is much better today. She is hearing normally. She is capable of doing
some physical work. No signs of vertigo. She doesn’t have any headache. She is
being discharged today.

DISCHARGE EPICRISIS
Patient XYZ Female Age: 33 years old
Date of admission: 24/12/2010 Date of being discharged: 31/12/2010.
Complaints: Her complains were vertigo, unilateral auditory dysfunction and tinnitus.
Investigations: During her stay in the hospital, general examination of ENT organs,
Pure tone audiometry.
Diagnosis: Bacterial meningitis followed by bilateral SNHL.
Treatment: She was treated by Betaserk, Thrombo ACC, Pyracetone, Vit B1, B6, A
Prognosis: good
Reccomendations:
Non medical- She was recommended to quit smoking, decreases alcohol and caffeine
intake, Low salt diet, decrease physical exertion, Slight rotational exercises.
Medical- Tab Betaserck 16 mg x 2 times per day for 2 months
Vit B1, B6 - i/m on Mon, Wed, Fri; Vit A orally – Tues, Thurs, Sat for 1 month
Tab prestarium 4 mg x 1 per day
Consult the Polyclinic ENT doctor after a month.
Treatment list

Reccomendations 24/12 25/12 26/12 27/12 28/12 29/12 30/12 31/12 At

home
Bed rest + + + + + cancelled - - -

Low salt diet + + + + + + + + +

Traing, exercises - - - - - + + + +

Tab Betaserk 16 + + + + + + + + +
mg x 2
Trombo ACC. + + + + + cancelled - - -
50mg x 1
Sol. Piracetone + + + + + cancelled - - -
5.0 x 1 i/m
Sol Vit B1, B6 – + - + - + - + - +
i/m

Vitamin A orally - + - + - + - + +

Tab. Prestarium + + + + + + + + +
4mg x 1

Analysis list:

Analysis 24/12 25/12 26/12 27/12 28/12 29/12 30/12 31/12

Otoscopy + - - - - - - +

Pure tone + - - + - - - +
audiometry
General blood + - - - + - - -
analysis
urine analysis + - - - - - - -

Analysis for HIV, + - - - - - - -

HBsAg, RPR (rapid
plasma regain test)
for syphilis.
Audiogram:
As of 24/12/2010.

After treatment, as of 31/12/2010