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