Date	Relevant Patient Data
December 3, 2017 (day 1/admission date)	Patient admitted with:
	Severe headaches;
	Convulsions;
	Difficulty swallowing;
	Polyuria;
	Polydipsia;
	Tachycardia;
	Positive Kernig’s;
	Right upper quadrant (RUQ) tenderness;
	Diagnosed with bacterial meningitis in a diabetic; with differentials of cerebral malaria, brain abscess;
	Labs
	1. FBS: 19.1 mmol/l Daily FBS
	2. PITC: non-reactive;
	3. LP for CSF analysis: biochemistry, microscopy, India ink, ZN staining.
	4. ESR: 87 mm/hr.;
	5. BS for MPS: 20 parasites per 200 wbcs;
	6. FHG, UECs, CT scan: patient did not do these because of lack of funds;
	7. Urinalysis: ph = 7.0; glucose +++; blood ++; SG 1.010; ketones nil; deposit: nothing seen.
	8. Abdominal ultrasound: normal abdominal scan, no renal or splenic abscess.
	Treatment:
	1. Diazepam 10 mg PRN
	2. Artesunate: 180 mg at 0, 12 and 24 h;
	3. Ceftriaxone 2 g BD for 10 days;
	4. Paracetamol 1 g tid
	5. Metformin 500 mg bd
	6. Dentogel cream apply QID on the oral lesions for 5 days.
	7. IV fluids 4 l of normal saline in 24 h
Day 2	Patient had four convulsions last night. Another which was partial occurs during the round.
	On examination: left sided paresis noted. All vitals including heart rate were now normal.
	Results:
	1. CSF: turbid; 60 cells/mm3; Pandy test negative; India ink positive; gram stain: no organism isolated; ZN negative; VDRL: negative.
	2. FBS = 17.4 mmol/l;
	3. I.V phenytoin 100 mg BD
	4. Fluconazole 1200 mg od for 2 weeks, then 400 mg od for 10 weeks; then 200 mg od for 6 months.
	5. Daily FBS; do UECs, FHG, CT scan of the head, TSH
	6. Continue with ceftriaxone, metformin, PCM, dentogel, and artesunate,
	7. Monitor for seizure occurrence and chart
Day 3	Reports improvement with no seizures reported; patient is now able to feed, has mild headaches.
	FBS not reported;
	Vitals normal (BP = 112/72 mmHg, pulse 97 bpm, SPO2 = 94%);
	Neck is soft and Kernig’s negative.
	Plan: continue with fluconazole, ceftriaxone, phenytoin, paracetamol, aremether-lumefantrine
Day 4–6	Reports some neck pains and headaches;
	On examination, patient is in fair general condition, vitals are normal;
	Neck is soft and Kernig’s negative;
	FBS oscillates between 13 and 14 mmol/l;
	Plan: continue with medication, do nutritional counseling because of diabetes;
Day 7	Patient complaints of frontal headache, itchiness on areas that had strapping used to secure IV lines, and gluteal itchiness
	FBS = 13.7 mmol/l;
	Patient is once again sick looking, with normal vitals (BP = 116/79 mmHg; SPO2 = 95%; pulse = 85)
	Neck is stiff and tongue lesions are still present on the edge of the tongue;
	Pruritic pustules on the areas with strapping, buttock has no eruptions;
	Plan:
	1. I.M diclofenac 75 mg PRN;
	2. hydrocortisone cream to apply bd;
	3. soluble insulin 5 IU tid;
	4. continue antimeningitics and phenytoin;
	5. do daily pre-dinner RBS and FBS.
Day 8	Patient still complaining of severe headache despite administration of three doses of diclofenac; the tongue ulcer is still painful and she is still itching;
	Patient is sick looking but with normal vitals;
	She still has the stiff neck, rashes and the tongue ulcers;
	Plan:
	1. 4mls of clear CSF tapped and sent for microscopy: India ink positive;
	2. Continue with the medication from the previous day.
Day 9	The headaches have improved and her vitals are normal;
	FBS = 20.9 mmol/l;
	Plan:
	1. stop the insulin;
	2. increase metformin to 1 g bd;
	3. continue with other medication.
Day 10–13	Patient reports improvement and her vitals are normal.
	RBS ranged between 8.0 and 13.1 mmol/l.
	Plan:
	1. continue with management as per treatment sheet i.e. ceftriaxone, fluconazole, metformin, glibenclamide, hydrocortisone cream and dentogel.
	2. Do serial CSF tapping if headaches are persistent.
Day 14	Patient has no complaints today.
	FBS = 8 mmol/l.
	Plan:
	1. Allow home on metformin 750 mg bd;
	2. Fluconazole 800 mg od for two weeks then 400 mg for 10 weeks;
	3. Dentogel, hydrocortisone cream, and omeprazole.
	4. To come again on 12th January 2018.
1st clinic visit (January 11, 2018)	Patient is doing well except for a flare up of her allergic rhino-sinusitis. Blood sugar was 5.8 mmol/l and a repeat lumber puncture was negative on India ink test.
	The need for dietary prudence and drug adherence was emphasized. She was then given fluconazole 800 mg od and asked to continue with metformin 750 mg bd, cetirizine 10 mg prn, omeprazole 20 mg bd and hydrocortisone.
2nd clinic visit (January 25, 2018)	Patient diagnosed with pneumonia;
	RBS = 8.2 mmol/l; BS for MPS was negative; CSF for India ink was negative for Cryptococcus;
	Plan:
	-septrin 960 mg bd for one week;
	-paracetamol 1 g tid for 5 days;
	-omeprazole 20 mg 1 h before supper for a month;
	-fluconazole 800 mg od for a month;
	-metformin 500 mg bd for a month;