Question

This is a Mystery Disease Assignment: Neurological Disorders

About the patient:

This is Beth. She is a 60 year old female. She’s a Native America who participates in crossfit, running as well as biking. She has no significant health issues. She presented to the ER with complaints of rapid onset fever, headaches, neck pain and stiffness, malaise, myalgias, anorexia and confusion.

GENERAL INFORMANTION: 60 years old Native American, ill appearing female. Unable to answer questions due to confusion, her husband relays PMH.

SKIN: Pale, diaphoretic.

LUNGS: Clear to ausculatation

CARDIOVASCULAR: Heart rate regular, S1S2 intact w/out murmurs, rubs or gallops. No jugular venous distention

ABDOMEN: Soft, nontender, nondistended, normal bowel sounds

MUSCULOSKELETAL: Nuchal rigidity, flaccid muscles

NEUROLOGICAL: confused mental status with altered consciousness, Coarse tremor, upper extremity myoclonus, positive Kernig sign

VS: BP 96/56, pulse98, Temp 38.4C, RR 24

More information from the patient (relayed by husband):

Have you had any exposures? Anyone else in the family with similar symptoms? Any recent trips?

No one else in the family has been ill.

We recently hiked on the Appalachian Trail for 2 weeks, we returned a week ago. Up until now she’s always been healthy and active.

How long has she been sick?

She started feeling achy and ‘like she was coming down with something’ a couple of days ago.

Then she developed the fever which got worse yesterday. Then she just started getting worse with confusion and twitching and complaining of severe headaches.

Any difficulty breathing, chest pain?

Not that she is complaining of.

Any nausea/ vomiting?

She was complaining of feeling nauseous when this first started but no vomiting. Probably because she doesn’t feel like eating.

Current Medications

Tylenol for fever and aches. She also takes a multivitamin and calcium supplement. But really nothing else.

Insect bites, tick bites?

We pulled off a couple of ticks during the trip, and of course, there were mosquitoes everywhere.

Did you drink stream water during the hiking trip?

We’re very careful with that. We did fill our canteens from a stream but used purifying tablets.

AFTER READING THE INFORMATION ABOVE ANSWER THESE 6 QUESTIONS BELOW. PROVIDE AS MUCH DETAILS AS POSSIBLE.

After knowing the information above, what 5 specific questions would you ask? (5 points)

Labs (2 parts): - (10 pts)

A) How will you continue your work-up? Here explain what each test is and in this case what you are looking for.

More Patient Information:

Labs: CBC w differential, CMP (Comprehensive Metabolic Panel), Sedimentation rate (assesses for inflammation), stool cultures of OVA and Parasites

Imaging: MRI of head and spine, lumbar puncture

Lab results:

HGB 15.0

WBC 3.2

Normal Neutrophils, lymphocytes

Sodium 146     Normal range 135-145

Potassium 4.2 Normal range 3.5-5.2

Chloride 110    Normal range 98-107

Bicarbonate 22 Normal range 22-28

Creatinine 1.1 Normal range 0.6-1.1

BUN 28         Normal range 8-24

ALT 20            Normal range 7-45

AST 40            Normal range 8-43

Stool cultures were negative

MRI was negative for acute process

Lumbar puncture: Demonstrates elevated protein, moderate pleocytosis with predominance of neutrophils. Cytologic exam shows plasmacytoid lymphocytes

B) List your findings so far (10 points)

Diagnoses: Short list of possible ailments (15 points)

What is your short list of 3 diagnoses with a rationale why you chose those. The rationale should show a direct relationship to the findings and ROS:

Plan: Follow up tests/studies (15 points)

This section is important because you will chose THE MOST LIKELY DIAGNOSIS IN YOUR OPINION and follow up with that one diagnosis only. These tests should be specific in nature and allow you to determine whether or not the patient has that particular problem/disease.

Pathophysiology: (25 points). Most important (4 sections) - Even if your diagnosis is not the actual one, as long as you have a good explanation for the ONE you chose, you WILL GET FULL CREDIT.

You need to describe how the disorder/disease you chose going forward MAKE the person feel sick

what the treatment is

how the treatment will counteract the disorder?

how it will affect the symptoms the patient manifests.

Follow-up ( 5 points)

Describe different things you would look for and ask about in a follow up appointment with Beth. You will be responsible for determining how the patient is responding.

Answer 1

Specific questions for patient

1) Does flexing of neck causes pain( to rule out for brudzinskis sign)

2) with knee flexed at 90 degree, is there any pain on extension of leg.( To rule out kernigs sign)

3) Is there any neck rigidity

4) have u suffered from any systemic illness recently.

5) Did u have any brain injury in the past

labs

CSF analysis for pressure, protein, glucose

CBC for WBC count

2) Findings

Ms Beth has Rapid onset of fever, neck pain and stiffness, mayalgias, nuchal rigidity, elevated CSF protein, flaccid muscles, positive kering sign, These signs show that patient is suffering from BACTERIAL MENINGITIS.

3) Follow up test and studies for bacterial meningitis

CNC( to rule out increased WBC count due to infection)

CSF examination

MRI ( to rule out changes in brain structure)

4) Pathophysiology

-Bacteria mostly Neisseria meningitis enter body

-It further enters into bloodstream and subarachnoid space

- bacterial inflammation leads to formation of exudates

-Adhesion form and arteries supplying subarachnoid space may be engorged with blood leading to rupture or thrombosis of vessel.

Treatment

Intervention depend on the causative microorganism and source of infection.

Commonly used antibiotics are cephalosporin, rifampicin and vancomycin.

Anticonvulsant for seizure prevention

Adequate fluid and electrolyte balance must be maintained.

Follow up

1) has the pain and rigidity reduced

2) Have u taken the complete dose of antibiotics without skipping any?

3) did u suffer from high fever after discharge.

4) how about nausea and vomiting?