Cases for finals #8 – History

45 year old man

  • sore throat for 1 week
  • mild generalised headache for last 3 days
  • last 24 hours been acting oddly – confused; speech garbled; drowsy
  • collapsed at lunchtime – went stiff, jerked arms and legs for two minutes
  • second attack 20 minutes later, in ambulance
  • still very drowsy on arrival at hospital

Your summary would be:

“Sub-acute neurological disorder charaterised by headache, confusion, seizures and depressed conscious level”

I reckon most of you will pick up on the preceding viral illness and be worried about an infectious process of the central nervous system.

It’s not unusual for students to plump for infection and inflammation ( -itis) of the brain lining (mening…) in this scenario, but there are a few things going on that worry me. First, there is confusion and reduced conscious level – whilst you can get this with meningitis, I would tend to localise these symptoms to the brain substance itself – encephal + itis = encephalitis.

If there are brain lining and brain substance symptoms, we call it meningoencephalitis.

The seizures are another big clue to the brain tissue being inflamed or damaged. Worse, the patient has not recovered consciousness from the last seizure – this could be “status epilepticus”.

What would you look for on examination?

What are your priorities?

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