Case stud y
1 Case Study
CASE RECORDS ofthe MASSACHUSETTS GENERAL HOSPITAL Founded by Richard. Cabot Eric S. Rosenberg, M.D., Editor Nancy Lee Harris, M.D., Editor Jo-Anne O. Shepard, M.D., Associate Editor Alice M. Cort, M.D., Associate Editor Sally H. Ebeling, Assistant Editor Emily K. McDonald, Assistant Editor Case 5-2014: 59-Year-Old Man with Fever, Confusion, Thrombocytopenia, Rash, and Renal Failure Meridale V. Baggett, M.D., Sarah E. Turbett, M.D., Shmuel S. Schwartzenberg, M.D., and James R. Stone, M.D., Ph.D. LOVE
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Chiet Complaint Male, 59 yrs Admitted because of fever confusion, thrombocytopenia, rash and renal failure R
3 Chief Complaint Male, 59 yrs Admitted because of fever, confusion,thrombocytopenia, rash, and renal failure
History of present illness Vomiting, diaphoresis and 3 increasing fatigue while traveling Feverish - Ibuprofen Nonverbal. unable to stand but able to respond to painful stimul
4 Vomiting, diaphoresis and increasing fatigue while traveling History of present illness 3 2 1 Feverish Nonverbal, unable to stand, but able to respond to painful stimuli Ibuprofen
History of present illness BP132/80mmHg P 110 bpm rr 26 breaths per min Naloxone and SpO294%(2L/min transferred Pupils 3mm and nonreactive BG8.2mmol/L E ECG sinus tachycarida(132 bpm)
5 History of present illness BP 132/80mmHg P 110 bpm RR 26 breaths per min SpO2 94% (2L/min) Pupils 3mm and nonreactive BG 8.2mmol/L ECG sinus tachycarida (132 bpm) Naloxone and transferred
History of present illness Physical Exam Laboratory EXam ■T:40.1°C ■ Toxicology P:130 bpm ■ HCT and wbc: normal BP: 103/71mmHg ■N%↑,PLT↓ RR: 26 breaths/min Nat. K+ cl normal Withdrawn BG normal ■ confused ■Lac↑cO21 ■GCs:14 ■Rena| and liver function↑ ■OB
6 History of present illness Physical Exam T: 40.1 °C P: 130 bpm BP: 103/71mmHg RR: 26 breaths/min Withdrawn confused GCS: 14 Laboratory Exam Toxicology: - HCT and WBC: normal N% ↑, PLT ↓ Na+,K+,Cl- :normal BG:normal Lac↑ CO2↑ Renal and liver function ↑ OB: +
History of present illness CT scan DlagnosisMeasures Brain Vancomycin Abdomen Ceftriaxone Pelvis Acyclovir no acute Diazepam abnormality Normal saline Acetaminophen Meningitis Indwelling urinary catheter Blood culture Urine culture Transporation
7 History of present illness Vancomycin Ceftriaxone Acyclovir Diazepam Normal saline Acetaminophen Indwelling urinary catheter Blood culture Urine culture Measures Meningitis Diagnosis Brain Abdomen Pelvis no acute abnormality CT scan
additional histor Feeling awful Two dogs Diffuse muscle pain Traveling in Ireland 1 month ealier Neck stiffness Hunting in brush in Pain with swallowing Nevada 10 days before TE LOVE No headache or Arriving in New rash England on the day LOVETEXTLEVE before the onset of Gout symptoms Drinking but no No dental work and no tick or mosquito bites smoKing
8 Additional History Feeling awful Diffuse muscle pain Neck stiffness Pain with swallowing Gout Drinking but no smoking Two dogs Hunting in brush in Nevada 10 days before Traveling in Ireland 1 month ealier Arriving in New England on the day before the onset of symptoms No dental work and no tick or mosquito bites No headache or rash
Vital signs General Other Signs Neurologic condition No murmurs exam T:36.1C Lethargic rubs or bruits · Impaired memory ·BP:125/81m Bowel sounds Diaphoretic present Fluent speech Soft abdomen . Diffuse weekness Flushed · Mottled skin P: 101 bpm Rash in Mute deep Unable to sit RR: 26/min livedo pattern endon reflexes in p Purpuric rash the ankle SpO2:94% Tender muscles. Flexor of plantar 2L/min) reflexes
9 Vital signs • T:36.1°C • BP:125/81m mHg • P: 101 bpm • RR:26/min • SpO2: 94% (2L/min) General condition • Lethargic • Diaphoretic • Flushed • Unable to sit up Other Signs • No murmurs, rubs or bruits • Bowel sounds present • Soft abdomen • Mottled skin • Rash in a livedo pattern • Purpuric rash • Tender muscles Neurologic exam • Impaired memory • Fluent speech • Diffuse weekness • Mute deep tendon reflexes in the ankle • Flexor of plantar reflexes
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