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Case Study 37By Chris Sanders
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History of Present Illness
86 y.o. male
Mosquito bite
Swelling around right eye
Bit 96 hours ago
Severe periorbital edema
Mild fever
Mild headache
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Review of Systems
Alert and oriented
Doctor suspects arthropod
Follow up appointment with neurologist and infections diseases specialist
OTC ibuprofen
Ice to swollen area
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Acute Viral Encephalitis
• What is the pathophysiology of swelling in this case?
• Why is the application of ice helpful to relieving swelling in this case?
• Based on the patient’s location when he received the mosquito bite, what are several possible diagnoses?
• Based on incubation period only, identify two potential types of encephalitis in this patient.
• Are any of the infections that you listed above in your answer to question 3 potentially serious?
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Clinical Course
Confused
Disoriented
Mild tremors
Severe headache
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Previous Medical History 18 months S/P cadaveric
renal transplantation
ESRD secondary to DM type 1, diagnosed 10 yrs
CAD
COLD x 6 yrs
Asthma
DM type 1 diagnosed at 13
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Medications Nitroglycerin SR 6.5 mg po Q
8h
Nitroglycerin 0.4 mg SL PRN
Theo-Dur 100 mg po BID
Albuterol MDI 2 puffs QID PRN
Atrovent MDI 2 puffs BID
Cyclosporine 250 mg po BID
Prednisone 10 mg po QD
Mycophenolate mofetil 1500 mg po BID
Insulin: NPH insulin 16 u @ breakfast and Lispro
Blood Glucose (mg/dL)
Units @ breakfast
Units @ lunch
Units @ supper
Units @ Bedtime
<80 4 - - -
81-150 5 - 8 -
151-200
6 - 9 1
201-250
7 2 10 2
251-300
8 3 11 3
301-350
9 4 12 4
351-400
10 5 13 5
>400 11 6 14 6
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Three of the drugs listed above are of particular concern in this patient.
Which three drugs should cause concern and why should they cause
concern?
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Nitroglycerin Dizziness, headaches, lightheadedness
Theo-Dur Dizziness, headaches, lightheadedness
Albuterol
Atrovent
Cyclosporine/Prednisone
Dizziness, headaches
Headache, eye pain
Suppresses immune system
Mycophenolate mofetil Suppresses immune system
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PE and Lab Tests Disoriented, pale, mild
tremors, appears ill
BP 150/95
P 105 and regular
RR 17 and unlabored
T 100.5º F
Warm and pale skin
No rash observed
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PE and Lab Tests Cont. PERRLA
EOM intact
Fundi reveal old laser scars bilaterally w/o hemorrhages and occasional hard exudates bilaterally
Ears and nose unremarkable with no bulging of TMs
Mucous membranes dry
Mild non-exudative pharyngitis present
Wears dentures
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PE and Lab Tests Cont. Thyroid normal
Cervical and axillary lymph nodes palpable (~2cm)
Sinus tachycardia
Chest normal
Abd normal
Rect normal
Ext normal
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PE and Lab Tests Cont. Disoriented
Mild tremor in both hands
DTRs 2+
(+) Kernig sign
(+) Brudzinski sign
Muscular strength 3/5
Decreased sensation in feet (diabetic neuropathy)
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• Suggest a reasonable explanation for the laser scars in the eyes?
• Suggest a reasonable pathophysiologic explanation for the patient’s enlarged lymph nodes.
• Although not routine practice, why were this patient’s feet carefully examined for lesions?
• What is suggested by the positive Kernig and Brudzinski signs?
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Lumbar Puncture Results Significant lymphopenia
Mild diffuse cerebral edema with no intra-cerebral bleeding
CSF lymphocytosis
Normal glucose
No CSF RBCs
Moderately elevated protein
Normal lactic acid
Gram stain (-)
Bacterial culture (-)
IgM antiviral antibody (+)
Enzyme Immunoassay with Plaque Reduction Neutralization Test
West Nile Virus
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• Based on all the available clinical evidence above, what is a likely diagnosis for this patient’s condition?• What is an appropriate treatment
approach for this patient?
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