A 60 year old male with fever, altered sensorium and cough Dr. Tayyab Muhammad Ali, PGR, Medical Unit I
A 60 year old male with fever, altered sensorium and
cough
Dr. Tayyab Muhammad Ali,
PGR, Medical Unit I
Particulars Patient name: Ehsan Elahi 60/y/M Resident of Sanda Lahore Retired Clerk DOA: 02/01/2014 Emergency Respondent Son and daughter-in-law
Presenting Complaints: Fever ------------------------------2days Altered state of consciousness----------- 2days Cough------------------------------------------ 1 day
The patient was perfectly well when started complaining of Fever which was continuous, high grade (104 F),
sudden in onset, associated with rigors and chills, not responding to antipyretics or tepid water sponging Associated with cough which was difficult to
expectorate because of sensorium Sore throat ◦, urinary complaints ◦, lumps or bumps ◦,
diarrhea ◦, ear pain ◦
Sore throat ◦, urinary complaints ◦, lumps or bumps ◦, diarrhea ◦, ear pain ◦
Joint pains/swelling ◦ Rash ◦ Weight loss/ Loss of appetite ◦ Family contact with fever or tuberculosis ◦ No contact with animals It was associated with altered sensorium No history of travel within the last month to outside of
Lahore
Patient was initially irritable, then progressed to drowsiness when he presented to us. During the course of admission he became comatose Slurred speech Irrelevant speech Facial, limb weakness◦ Visual complaints vomiting ◦ Headache ◦ Fits ◦
Cough associated with fever as described. Difficult to expectorate as patient was in altered state of consciousness. Long bouts of cough that did not respond to nebulization or expectorants
The patient was admitted for workup and treatment and as mentioned sensorium worsened during the stay
Photophobia ◦, no exposure to gardening ◦, no exposure to pets ◦, foreign travel ◦,
• Oliguria ◦, abdominal distention ◦, hemetemesis ◦, • Photophobia ◦, no exposure to gardening ◦, no
exposure to pets ◦, foreign travel ◦, blood transfusions ◦, dental/surgical procedure ◦
Sexual history could not be elicited in detail Systemic enquiry showed no significant data
Past Medical/Surgical History Nothing of note
Personal History DM ◦ HTN ◦ TB ◦ HBC ◦ HCV ◦ HIV ◦ Smoking 20 pack years
Family History DM, HTN mother Father died of Liver disease, probably CLD No family history fever disease or disorders No family contact with fever
Drug History No known drug allergies Not using any drugs OTC or otherwise No hakeem or homeopath drugs
Allergies History of urticaria and diarrhea associated
with fish meat
Socioeconomic Higher middle class Children overseas
Provisional Diagnosis
Meningeoencephlitis + Aspiration pneumonia Cerebral Abscess + Aspiration pneumonia Tuberculous meniningitis Atypical pneumonia Lymphoma Sepsis 2◦ to Pneumonia or any other infection
GPE- OVERVIEW An old age gentle man lying in bed, comatose,
eyes spontaneously open but not responsive GCS of 5/15
GPE-vital signs BP 100/80 mmHg RR 38/min Temp 103 ◦F Pulse 110/min
Rapid, regular, low volume, normal wave form, symmetrically palpable in both limbs.
pallor ◦ Cyanosis+ Koilonychia ◦ jaundice ◦ Good oral hygeine Lymph nodes ◦ Conjunctival redness + Rash ◦ Edema ◦
Specific Signs Brudzinski’s Positive Kernig’s Negative
Neurological Examination PUPILS:
Mid-dilated, symmetric, bilaterally reactive to light.
EYES: No motor deficit apparently elicitable.
CRANIAL NERVES: Intact
MOTOR EXAM Patient occasionally moved limbs, not favoring any
particular side
Planters downgoing Reflexes Normal, symmetric bilaterally
SENSORY: Patient responded to pain and tried to localize it,
however this finding deminished during admission and became completely unresponsive to pain
CEREBELLAR, AUDITARY, VISUAL EXAMINATION could not be carried out in detail
Respiratory System Trachea pushed towards the right Left lung base, dull to percussion, reduced
breath sounds, no vocal fremitus or resonance Rest of the pulmonary exam normal
CVS Pulse described Apex beat could not be located despite
moving the patient S1 low intensity, Normal intensity S2. No
added sounds or murmurs
GIT Abdomen normal shape, normal umblicus Liver ◦, Spleen ◦ Abdminal masses ◦ Lymph nodes ◦ Normally audiable bowel sounds
Review of Differential Diagnosis
Meningeoencephlitis + Aspiration pneumonia Cerebral Abscess + Aspiration pneumonia Tuberculous meniningitis Atypical pneumonia Lymphoma Sepsis 2◦ to Pneumonia or any other infection
BASELINE INVESTIGAITONS
BIOCHEMISTRY
CSF
PLEURAL FLUID EXAM Turbid RBC 400 TLC 900 NEUT 80 % Glucose 34 mg/dl PROTEIN 9.0 mg/dl LDH 576 U/L
CXR
ULTRASOUND Liver, spleen normal in size Unremarkable Confirmed pleural effusion on left side
CT BRAIN
FINAL DIAGONSIS PYOGENIC MENINGITIS AND CONCOMITANT
PYOGENIC PLEURAL EFFUSION