推 sorrowfulboy:TB meningitis or brain infection? 11/05 08:37
A 72-year-old man presented with altered mental status for 1 week
Present illness
Intermittent low grade fever (37-38) about every week for 3 months
Especially in the evening
No cough, sputum, abdominal pain, dysuria, URI symptoms, bone pain or
bowel habit changes
Only headache while fever flared up
More and more forgetful in recent 2 months
Capable of all self-care => diaper all day
Consciousness became more and more lethargy in recent 1 week
Denied head injury
Sent to our ER by his wife
What else do ou want to ask to approach a patient with fever
Past history
Hypertension without medical control
Left hip fracture (traffic accident), s/p total hip arthroplasty 5-6 years ago
Smoking: denied
Alcohol: social
Alelrgy: no known allergy
Denied travel history, or animal exposure
Medications or herb: denied
Occupation: factory worker, retired
Family history
No malignancy, DM, tuberculosis exposure history of family member
No family member became sick recently
Physical examination
Height: 160 cm Weight: 43.5 kg BMI 17 kg/m2
Consciousness: E3V1M5, drowsy
BT: 36 C, HR: 81 /min, RR: 20 /min, BP; 180/114 mmHg
HEENT: pink conjuctiva, anicteric sclera
Pupils: 3.5 mm/3.5 mm; light reflex: +/+
Neck: stiffness; jugular vein engorgement (-), no LAPs; no goiter
Chest: symmetric expansion, spider angioma (-)
Breath sound: no wheezes or crachles, bilateral coarse
Heart: regular heart beats without murmurs
Abdomen: soft and flat, no tenderness, normoactive bowel sound, no flank
knocking pain
Extremities: warm; no pitting edema
Muscle power: bilateral 2, no obvious asymmetry
Babinski sign: ↓/↓
What is your differential diagnosis about consciousness disturbance?
What is your next step?
EKG
Chest X-ray
Lumbar puncture
Open pressure 160 mmH2O
Closed pressure 85 mmH2O
Protein 180.8 mg/dL
Glucose 32 mg/dL
Serum glucose 110 mg/dL
RBC 4
WBC 18
L:N 3:15
Appearance colorless
Cryptococcus Ag -
RPR -
Acid-fast stain -
Indian ink -
Gram stain: no bacteria
How to interpret this findings of CSF?
Hospitalization course
11/1
Ceftriaxone 2 g iv Q12H
Ampicillin 2 g iv Q4H
Airborne isolation
Sputum acid-fast stain (11/3, 11/4): 1+
Consciousness improved and fever subsided gradually
COmplained severe back pain
What is your next step?
How to approach a patient with back pain?
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