Cases for finals #8 – Examination

  • Temp 38 C
  • Speech – not following commands; occasional words spoken
  • Higher mental function (HMF) – drowsy but able to rouse
  • Cranial nerves – normal (fundi hard to see)
  • ULs/LLs – not moving right side much, but withdraws from pain on that side
  • No signs of seizure activity

OK. Big problems here.

First priority – ABCDefg (airway, breathing, circulation, don’t ever forget glucose)

Next step – phone for help; this patient is very, very ill

There are “focal” signs of cortical dysfunction (language, hemiplegia) and fever. This has to be more than meningitis. I would be very worried about viral encephalitis and the top culprit is Herpes Simplex type 1 (HSV 1). This can be fatal if not quickly diagnosed and managed.

Treatment broadly and then hone in on the bug once you have some more information.

Some specific management tips:

  • Bloods – general plus cultures; ABG could tell you if there is a major metabolic insult
  • iv access
  • urgent iv antibiotics and iv antiviral therapy (aciclovir)
  • anti-epileptic medication – this patient will fit again if you’re not careful
  • urgent brain scan – MRI or CT (preferably MRI)
  • urgent LP – if safe to do so
  • HDU or ICU

 

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