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

Brudzinskis Positive Kernigs Negative

Neurological Examination

PUPILS:

Mid-dilated, symmetric, bilaterally reactive to light. No motor deficit apparently elicitable.

EYES:

CRANIAL NERVES:

Intact
Patient occasionally moved limbs, not favoring any particular side

MOTOR EXAM

Planters downgoing Reflexes Normal, symmetric bilaterally Patient responded to pain and tried to localize it, however this finding deminished during admission and became completely unresponsive to pain

SENSORY:

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