Case Conference October 1 st, 2013 Phuong Dinh, Ben Triche & Alisha Lacour

  Headache X 5 days Chief Complaint

  63 year old male with a PMH diverticulitis and Hepatitis B  8 days prior to presentation: has non-bloody, watery diarrhea that lasted for 2 days and resolved spontaneously.  5 days prior to presentation: Pt developed a sharp, stabbing left-sided frontal headache, that gradually worsened.  Headache was centered over Left temple and radiated up to his scalp.  Pt admitted to fevers, chills, blurred vision, arthralgias, and myalgias.  He denied shortness of breath, cough, neck stiffness, confusion, N/V, or any other symptoms. HPI

  Diverticulitis  Hepatitis B (1971)  Chronic Lower Back Pain Past Medical History

  Lasik  Back Surgery Past Surgical History

  NKDA Allergies

  Celecoxib 100mg PO BID Medications

  Mother died of heart disease  Father died of Alzheimer’s Disease  2 Brothers with Heart disease Family History

  Smokes 1 pack per day for 50 years  Rarely drinks on special occasions  Denies any illict drug use  Lives at home alone  Retired massage therapist Social History

  Not up to date on influenza immunization  Not up to date on Tetanus immunization  No colonoscopy Health Maintenance

  Constitutional: Positive for fever and chills.  HEENT: Negative for hearing loss, ear pain, facial swelling, neck pain, neck stiffness and ear discharge.  Eyes: Negative for pain, discharge, redness and itching.  Reports of blurriness of vision and mild photophobia associated with his headache.  Respiratory: Negative for apnea, shortness of breath and wheezing.  Cardiovascular: Negative for chest pain, palpitations, leg swelling and syncope. ROS

  Gastrointestinal: Positive for diarrhea. Negative for abdominal pain.  Genitourinary: Negative for dysuria and hematuria.  Musculoskeletal: Positive for back pain.  Neurological: Positive for headaches. Negative for dizziness, speech change, focal weakness, seizures, loss of consciousness, facial asymmetry, weakness and numbness.  Psychiatric/Behavioral: Negative for memory loss and altered mental status. ROS (cont’d)

 Physical Exam  Triage Vitals  Temperature 98.0° F  Blood Pressure 145/80  Pulse 96  Respiratory Rate 16  O2 Sat 93% on RA  Height 5’8”  Weight 79 kg  BMI 26  Exam Vitals  Temperature 101.7° F  Blood Pressure 107/79  Pulse 88  Respiratory Rate 16  O2 Sat 96% on RA

  GENERAL: Awake, alert, and oriented. Squinting in pain.  HEENT: PERRL, EOMI, Left temporal artery more prominent than right. No tenderness to palpation. Decreased visual acuity of left eye (20/200- left vs. 20/100- right).  NECK: supple, no nuchal rigidity  CARDIOVASCULAR: Tachycardic, Regular rhythm. No murmurs. 2+ radial and DP pulses.  RESPIRATORY: No increased work of breathing. No crackles, rales, wheezes  ABDOMEN: Bowel sounds present. Soft. Nontender. Nondistended.  EXTREMITIES: No clubbing, cyanosis, or edema. Physical Exam

 Labs Ca 8.5 Mg 1.6 Phos 2.1 TP Alb TB AST ALT ALP N 92 L 4 M HIV – nonreactive U/A - WNL ESR - 72 (0-20) CRP – (<0.90) (<45) (<46)

 Electrocardiogram

  After initial workup, differential diagnosis were:  Trigeminal Neuralgia  Temporal Arteritis  Given his elevated ESR and CRP he was started on prednisone 60mg  Medicine was consulted for admission ER Course

  After Medicine Oncall Team had finished evaluation of patient and were writing admission orders, the patient spiked a temperature of 105.3, which prompted further workup.  Patient was empirically started on Vancomycin, Ceftriaxone, Ampicillin, and Ciprofloxacin for suspected meningitis  The Medical ICU was consulted  Lumbar Puncture was performed ER Course (cont’d)

  CSF Clear  Glucose 90 (40-70)  Total Protein 49.6 (15-45)  WBC 0  RBC 2 Lumbar Puncture Results

  Additional Lab Orders placed:  Blood cultures  Urine culture  Legionella Antigen  Hepatitis Panel  T spot  Rheumatoid Factor  ANA  Cryoglobulin Additional Lab Orders

 CXR

 CTA Chest



 CT Head

  The patient was admitted to the ICU with the following active problems:  Sepsis secondary to pneumonia  Continued on Vancomycin, Ceftriaxone, Ampicillin, and Ciprofloxacin  Temporal headache  Continued on Prednisone Hospital Course

  The patient was afebrile and was stable for transfer to the floor.  Ophthalmology was consulted for evaluation due to concern of Temporal Arteritis. A full eye exam was performed showing sharp disc margins, and no evidence of temporal arteritis.  Neurosurgery was consulted for temporal artery biopsy.  Prednisone was continued.  Antibiotics were changed to Ceftriaxone and Azithromycin for Community Acquired Pneumonia. Hospital Course – day 2

  Patient had a temperature of overnight.  Vancomycin added back to cover for potential post- viral MRSA pneumonia.  Neurosurgery planning for temporal artery biopsy. Recommending an MRI to better workup abnormality seen on CT imaging. Hospital Course – day 3

  MRI Brain completed  Patient’s Legionella Antigen resulted Positive  Antibiotics were changed to Ciprofloxacin 400 IV q12  This was selected secondary to cost of medication Hospital Course – day 4

 MRI Brain







  Films reviewed with Neurosurgery. Pt has cavernous malformation in Left basal ganglia. This could not be removed safely because of its location in eloquent brain. It was recommended to repeat MRI in 3 months and follow up in Neurosurgery clinic for follow-up.  Neurology evaluated the patient who believed that the patient has Trigeminal Neuralgia and recommended Carbamazepine. Hospital Course

  Patient was continued on IV Ciprofloxacin for 2 more days and then discharged on Ciprofloxacin 750mg PO BID x 14 days.  He continued Carbamazapine outpatient for his headaches and was given follow up with Neurology.  Repeat MRI scheduled for 3 months from discharge. Hospital Course

  Legionella Pneumonia  Trigeminal Neuralgia Diagnosis

  Thank You