CASE OF EH

GENERAL DATA
66 year old
Right-handed
Male
Married
Filipino
Roman Catholic
Quezon City

FEVER AND
DECREASED
SENSORIUM

Chief Complaint

HISTORY OF PRESENT ILLNESS

1 ep of nape
to occipital
pain
Undocumente
d Fever
Paracetamol

No recurrence
of headache
Intermittent
undocumented
fever
Generalized
body
weakness
Easy
fatigability
Paracetamol

Worsening of generalized body

weakness
3x vomiting
BP
131/87
Brought
to nearest ER in Bulacan

Requested CT, but unavailable at

hospital, opted THOC
Noted with jerking of the right leg

Seizure: twitching of right face,

stiffening and flinging of right side,
rolling of eyeballs
Urinary
Phenytoinincontinence
and Diazepam given
Given mannitol 200cc, omeprazole,
paracetamol, acyclovir, valproic acid
Referred to neurology (Dr Limcauco)
LP: increased pressure, turbid CSF
Initial CSF studies: India ink no
encapsulated budding yeast seen,
elevated protein level
Decreased sugar level
TCC 577 WBC 577 L85 N475
(-) KOH and GS
Started on Ceftriaxone, D/C Acyclovir
Intubated at around 11am

7 days PTA

Interim

1 day PTA

DOA

REVIEW OF SYSTEMS
Constitutional: No weight loss
Respiratory: No cough, colds or dyspnea
Cardiac: No chest pain, orthopnea, PND, or palpitations
Gastrointestinal: No abdominal pain, diarrhea, or constipation

REVIEW OF SYSTEMS
Genitourinary: No dysuria, hematuria, nocturia, urinary
urgency or frequency
Endocrine: No tremors, heat/cold intolerance
Hematology: No active bleeding, bruises/ hematoma, or easy
fatigability
Musculoskeletal: No atrophy, edema

PAST MEDICAL HISTORY

(+) Hypertension maintained on felodipine 5mg/tab OD
UBP 120/80, HBP 160/90

(-) Diabetes Mellitus, Bronchial asthma, or PTB

(-) Prior Surgeries

PERSONAL SOCIAL HISTORY

22 pack year smoker
Occasional alcoholic beverage drinker
IV drug use unknown to relatives
Recent travel: 2 months PTA- Davao and Cebu
Wife claims to be monogamous with no history of STD

FAMILY HISTORY
(+) Hypertension, diabetes mellitus and bone cancer

Physical Examination
System

Findings

General Survey

Stretcher-borne, not in cardiorespiratory distress

Vital Signs

BP 173/100 HR 140 bpm

Dermatologic

No noticeable skin lesions. Skin warm and moist. No active dermatosis

Head
Eyes
Ears
Nose
Throat

RR 21 cpm

Temp 40C

Atraumatic. Normocephalic
Pink palpebral conjunctivae and anicteric sclerae.
No tragal tenderness. No aural discharge. Tympanic membrane, intact.
Septum midline. No nasal discharge. No congestion.
Moist lips, tongue, buccal mucosa, no tonsillopharyngeal congestion

Physical Examination
System

Findings

Neck

No palpable cervical lymphadenopathies, no neck vein engorgement, thyroid

not enlarged, no bruit

Thorax

Symmetric chest expansion. No costal retractions. Lung fields resonant.

Clear breath sounds.

Cardiovascular

Adynamic precordium. No thrills or heaves. Normal rate and regular

rhythm. Distinct S1 and S2. No murmurs

Abdomen

Slightly protuberant abdomen. Normoactive bowel sounds. No direct

tenderness on all quadrants. No organomegaly.

Back

No costovertebral angle tenderness

Extremities

No peripheral edema and varicosities on the extremities. No cyanosis. Full

and equal pulses.

Neurologic Examination

Mental Status Examination

GCS 8 (E2 V1 M5)
E

Partial eye opening to pain

None

Localizes pain on the left upper extremity

No regard
Does not follow commands
No tonic extension or clonic
movements of the extremities

Neurologic Examination

CN I
No Anosmia
CN II Pupils 2 mm equally & briskly reactive to
light;
(+) direct and consensual reflexes
(+) visual threat on all quadrants;
midposition;
Fundoscopy: (+) ROR, no
papilledema
CNIII
CNIV
CNVI

Intact EOMs

Neurologic Examination

CN V V1 to V3 intact,
(+) Corneals, left eye
CN VII No apparent facial asymmetry
CN VIII

(+) Dolls eye reflex

Neurologic Examination

CN IX Uvula midline, good gag

CN X Symmetrical palatal elevation
CN XI Not assessed
CN XII Tongue midline
No fasciculations

Neurologic Examination

+
5/5
++
100%

+ 5/5
++
100%
++

++

SENSORIMOTOR
Good muscle tone, localizes on the left upper
extremity; withdraws to pain on the left
lower extremity; right upper and lower
extremities do not withdraw to pain
REFLEXES
Hyporeflexia
No toe-extensor (Babinski) sign

++
+
++
++

++
+

5/5
100%

++
++

MENINGEAL
(+) Nuchal Rigidity
(-) Kernigs
(-) Brudzinskis

Salient Features
SUBJECTIVE
66 year old, male
Right handed
Sudden onset of nape pain and
occipital headache with
undocumented fever relieved by
Paracetamol
6 days later sudden onset of
generalized body weakness with
several episodes of vomiting and
seizure

OBJECTIVE
GCS 8 (E2V1M5)
No regard, does not follow commands
Hypertensive, tachycardic, febrile
No facial asymmetry
(+) Corneals left eye
(+) Nuchal rigidity
(-) Kernig and Brudzinski
Localizes pain on the left upper
extremity; withdraws to pain on the left
lower extremity
Right upper and lower extremities do
not withdraw to pain

SALIENT FEATURES
66y/o male
7day history of headache associated with vomiting, and
undocumented fever, presenting with seizure on day of
admission
no cough, colds; no prior complaints of abdominal pain or
changes in bowel habits; no change in appetite or recent
significant weight loss
smoker (22pack-years); non-promiscuous

SALIENT FEATURES

GCS 8 - E2V1M5, localizes

2mm EBRTL, (+) corneals, cephalo
No sensorimotor deficits
Nuchal rigidity

IS THERE A NEUROLOGIC PROBLEM?

Headache
Vomiting
Decrease in sensorium
Nuchal rigidity

IS THERE A NEUROLOGIC PROBLEM?

Headache
Vomiting
Decrease in sensorium
Nuchal rigidity
Focal motor seizure, right-sided

WHERE IS THE LESION?

Decrease in sensorium
ARAS
Diffuse bilateral cerebral
hemispheric lesions

Decrease in sensorium
ARAS
Diffuse bilateral cerebral
hemispheric lesions

Nuchal Rigidity
Meningitis
Subarachnoid hemorrhage

Focal Motor Seizure

WHAT IS CAUSING THE PATIENT'S

SYMPTOMS?

Major Categories of Neurologic Disease

CSF-related
Neoplastic
Infectious
Vascular
Traumatic
Seizure-related

Demyelinating
Metabolic
Degenerative
Developmental
Nutritional
Toxic

Major Categories of Neurologic Disease

CSF-related
Neoplastic
Infectious
Vascular
Traumatic
Seizure-related

Demyelinating
Metabolic
Degenerative
Developmental
Nutritional
Toxic

Major Categories of Neurologic Disease

CSF-related
Neoplastic
Infectious
Vascular
Traumatic
Seizure-related

Demyelinating
Metabolic
Degenerative
Developmental
Nutritional
Toxic

Major Categories of Neurologic Disease

CSF-related
Neoplastic
Infectious
Vascular
Traumatic
Seizure-related

Demyelinating
Metabolic
Degenerative
Developmental
Nutritional
Toxic

Differentials

Primary Neurologic Impression

t/c Viral Meningoencephalitis
Focal onset seizure with impairment of consciousness
involving the left frontal area, probably secondary to
encephalitis, rule out vasculitis from CNS infection

Course in the Wards

Temp

WBC

40.5
47000

47500

40.0

42000

39.5
40000
39.0

38810

37000

38.5

Temperature

32000

38.0

WBC
27000

37.5
22000

22680
20920

37.0
18160

18750

17000

17390

36.5
15240
36.0

35.5

12890

14180

12000

7000