Intern Report Case 1.14

Presented by Alison Loynd, DO

HISTORY

A 35-year-old female is transferred from an urgent care center by EMS with chief complaint of altered mental status and fever. The patient is unable to answer questions. She is approximately 18 weeks pregnant and febrile. She has no nausea, vomiting, dyspnea or noted seizure activity. Her boyfriend reports that the patient was previously healthy. She had a dental extraction approximately one month prior. Since that time, she has had pain all over, headache, nausea and vomiting. She was seen in the ED one week ago and given antibiotics for dental infection. The patient has been taking antibiotics as prescribed for the last week.  She went to the dentist office today complaining of headache and facial swelling. At the clinic, she had a procedure done but the boyfriend does not know any more specifics. He reports that afterwards she was unable to ambulate and felt dizzy and weak.  Due to her changes in mental status, they called 911.

PMH: None per friend.
PSH: None per friend.
GYN: G1P0 currently 18 weeks pregnant with routine prenatal care.
Meds: Cephalexin and Amoxicillin x 1 week.
Allergies: None known
Social: She does not drink, smoke or use illicit drugs.

PHYSICAL EXAM
GENERAL: The patient is obtunded, at times somnolent but arousable to her name. She opens her eyes and moves extremities spontaneously. She is making no vocalizations.
VITALS: BP 145/85  HR 121  RR 20 Temp 39.2 R  94%RA
HEENT: Head is atraumatic, normocephalic. TM clear and intact bilaterally, no effusion or hemotympanum. PERRLA. 2mm bilaterally. Mucous membranes are dry. No tonsillar edema or exudates. There is some mild edema of the left mandible, it is not indurated or fluctuant. Left mandible and cheek are tender to palpation. Neck is supple. Trachea midline with no lymphadenopathy.
HEART: Tachycardic and regular No murmur, gallop or rub.
LUNGS: Clear to auscultation bilaterally with shallow breathing
ABD: Soft. Gravid. Fundus palpable below umbilicus. Bowel sounds are hyperactive.
EXT: No edema or cyanosis. She has full range of motion spontaneously. Pulses present and equal bilaterally.
SKIN: Hot and dry. No noted edema, cyanosis or rash.
NEURO: Patient has a GCS of 11 (3E, 2V, 6M). She is opening her eyes, initially following simple commands, moves spontaneously. She is not vocalizing. She has an intact gag. Face appears symmetrical. Her patellar and Achilles reflexes are normal with no clonus.

LABORATORY EVALUATION
CBC: WBC 23.8 (22.4 Neutrophils) / Hgb8.8/ Hct 26.7/ Platelets 352
LYTES: Na 133/K 3.2/HCO 19/BUN 6/Cr 0.6/Glucose 130   Mag 1.5 Ca 8.2
CSF: Hazy, 750 RBC, 700 nucleated cells, 93 N, 5 L, glucose < 20, protein 122
GS: No organisms on gram stain. Numerous PMNs, mod RBC
UDS Positive for cannibis

Bedside US: Active intrauterine fetus, heart rate 178. Gestational age 19 weeks by femur length and 20 weeks by fundal height.

QUESTIONS

1.    Considering your differential evaluation, what is most likely in this patient?
A.    Trauma
B.    Encephalitis/meningitis
C.    Brain Abscess
D.    Preeclampsia
E.    Saggital sinus thrombosis

2.    What is your diagnostic test of choice?
A.    CT with and without contrast.
B.    LP and serology.
C.    CT without contrast.
D.    Obtain 24 hour urinalysis, liver function and platelets.
E.    MRI.

3.    Treatment considerations include:
A.    Anticoagulation with heparin.
B.    Antiepileptic prophylaxis – IV phenytoin.
C.    Multiple antibiotics: IV Penicillin, Metronidazole, Ceftriaxone and glucocorticoid.
D.    Antihypertensive – IV hydralazine.
E.    Single antibiotic regimen – IV Clindamycin

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