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
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
134 100 123.4 25 1.02
168
Ca 8.5 Mg 1.6 Phos 2.1 TP Alb TB AST ALT ALP6.9 3.2 0.7 101 110 92
11.1 191
14
41.9
N 92 L 4 M 3
93
13.5
HIV – nonreactiveU/A - WNLESR - 72 (0-20)CRP – 23.96 (<0.90)
(<45)(<46)
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)
Additional Lab Orders placed:
Blood cultures Urine culture Legionella Antigen Hepatitis Panel T spot Rheumatoid Factor ANA Cryoglobulin
Additional Lab Orders
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 101.0 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
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