Case Management Conference

ALTERED STATE
Bernadette Montano
Resource Speaker: Dr. Sherwin foronda
February 10, 2023

GENERAL OBJECTIVE

• To discuss a case of a patient presenting with acute onset of headache, progressing with decreased
sensorium, and seizure
•
SPECIFIC OBJECTIVE

• To be able to correlate the history, physical examination findings, diagnostic and treatment approach of a patient with
CNS infection: meningitis according to Harrison’s Principles of Internal Medicine 20 th Edition.
• To briefly discuss the pathophysiology in CNS infection, meningitis

HISTORY AND PHYSICAL EXAMINATION

GENERAL DATA

LMM 18/M, a single, Catholic, Senior High School student, born and raised in Cabuyao, Laguna admitted for the
first time at City of Gen. Trias Doctor’s Medical Center.

Informant: Mother

CHIEF COMPLAINT: Decreased Sensorium, Seizure

HISTORY OF PRESENT ILLNESS:

Patient was apparently well, started to experience headache 1 week prior to admission: heaviness, throbbing,
moderately controlled with analgesics, with no history of head trauma/accident, then developed photosensitivity, and was
feverish, rendering the patient not able to do daily life activities.

3 days prior to admission, patient was noted to have progressively increased sleeping time, and seemed not
himself, was agitated when tried to be awakened, with documented fever 38.3-38.5, with no associated cough, colds,
throat pain, ear discharge, dysuria, diarrhea, nausea and vomiting, myalgia, joint pains, rashes, broken/bite skin lesion,
tepid sponge bath was done, and given paracetamol. Patient was constantly complaining of headache, noted to have
body malaise, with poor oral intake.

Until night prior to admission, patient was difficult to arouse, was seen with stiffening of jaw and extremities,
drooling of saliva, and upward rollig of eyeballs lasted for ~1 minute, hence was brought to a nearby local hospital. He
was then uncooperative, irritable, and combative, with recurrence of seizure twice at the ER, given Diazepam and

Page 1 of 5
Paracetamol and was advised transfer to an institution with a Neurology Specialist. patient then was transferred and was
admitted at our institution.

PAST MEDICAL HISTORY

Patient has no known co-morbidities: no hypertension with usual BP of 110-120/70-80, no diabetes, no bronchial
asthma, no thyroid disorder, no known allergies to food and medications
Completed childhood immunizations
2 doses Covid Vaccination completed February 2022
no history of seizure in early and late childhood

FAMILY HISTORY

Patient has family history of Hypertension on maternal side

No familial history of epilepsy, CV events, Cerebrovascular Disease, Kidney Disease,

PERSONAL AND SOCIAL HISTORY

Patient is a non-smoker, non alcoholic beverage drinker. No exposure to toxins, no illicit/controlled substance
use/abuse. No history of inter-regional and out of the country travel

REVIEW OF SYSTEMS

Patient has no weight loss, abdominal pain, changes in bowel movements

PHYSICAL EXAMINATION

GENERAL SURVEY

Patient appears well nourished, well developed, mesomorphic, appears her chronological age of 18, non-
ambulatory, lethargic arousable to rigorous tapping, non-conversant, not able to follow commands, combative, GCS 10
(E2V3M5).

VITAL SIGNS

BP 110/80 mmHg HR 82 bpm RR 20 cpm Temperature 38.4°C O2sat 96% rm air

ANTHROPOMETRIC

Weight 65kg Height 173 cm BMI 21.7 kg/m2 (normal)

SHEENT

No pallor. No petechial rashes. Skin is warm to touch. Good capillary refill without nail clubbing. Head is
normocephalic with no gross deformities and soft tissue swelling, no facial edema with no pale palpebral conjunctiva.
Moist lips and oral mucosa, no dental carries, no gingivitis, Tonsillopharyngeal wall is non-hyperemic, non-hypertrophic.
No cervical lymphadenopathy. No visible or palpable anterior neck mass. Non-engorged neck veins.

Page 2 of 5
CHEST & LUNGS

No chest deformities with no sternal retractions, no obvious masses, or lesions. Symmetrical expansion. Vesicular
breath sounds, no adventitious breath sounds.

CVS

No precordial bulge. PMI at 5th ICS left mid-clavicular line. No heaves, no thrills, no tenderness. Upon
auscultation, normal rate with regular rhythm. No murmurs, no third or fourth heart sounds. Full and equal pulses.

ABDOMEN

Non distended, flat abdomen, no violaceous striae, no engorged visible blood bessels. Normoactive bowel sounds.
Soft no tenderness. Generally tympanitic to percussion.

ANORECTUM/GENITAL

No lesions, no discharge, no inguinal lymphadenopathies; DRE not done

EXTREMITIES

Full and equal peripheral pulses. No varicosities noted. No deformities, asymmetry or lesions. No edema, good
capillary refill, no limitaions in active and passive range of movement.

NEUROLOGIC

Patient is lethargic, arousable after rigorous tapping, able to localize and with verbal
response appropriate with pain, combative, and does not follow commands
Disoriented, no regard
pupils are round, 2-3mm equal and are bilaterally briskly reactive to light, with intact corneal
reflex.
no facial asymmetry, equally strong and reactive facial muscles.
intact gag reflex non slurred speech
motor strength of 5/5 on all extremities
patellar and biceps tendon reflexes with normal brisk response
with nuchal rigidity, (+) kernig’s sign, (+) Brudzinski's sign

Initial Impression:

CNS Infection, bacterial menigitis

COURSE DURING ADMISSION

D0 ER-ICU Patient was noted to have decreased sensoruim, airway was assessed, hemodynamically stable.
Venoclysis was started, with PNSS 1L x 8 hours, diagnostics were done ( CBC, blood chem), NGT was inserted,
managed accordingly: Dexamethasone 4mg TIV Q6, Mannitol 200cc IV bolus then 100cc IV bolus q6, Ketorolac 30mg q8

Page 3 of 5
for the headache, Diazepam 5mg bedside for frank seizure, antibiotic Ceftriaxone 2G TIV q12 was started. Patient was
then referred to Anesthesiologist, Lumbar Puncture CSF collection was done under IV sedation (Midazolam 2.5mg +
Nalbuphine 5mg + ketamine 25mg), and specimen was sent for analysis.

HD1 ICU Patient was stuporous, with no verbal output, with movement of all extremities, pupils 2-3 mm equally
briskly reactie to light, was with stable normal blood pressure 110-130/70-80, still with febrile episodes, with 1 seizure
episode. Leviteracetam 500mg 1 cap BID was started. Was scheduled for Contrast enhanced Cranial CT scan. Medical
management was continued.

HD2 ICU Patient was then fully awake, oriented and coherent, folllows commands, no febrile episode, no focal
neurologic deficit, with moderate headache, no dizziness, no vomiting; oral diet was started with SAP, tolerated.

HOSP D3-5 Patient was with no subjective complaints, was then transferred to regular room. Mannitol was then
decreased to 75cc q8 3 doses and then was discontinued; IV dexamethasone was shifted to oral rout 4mg tablet TID.
Ceftriaxone was continued to complete 5 days.

HOSP D6 Patient had no subjecctive complaints, was with stable vital signs, no seizure, hence was discharged
improved. Home medications were: Cefixime 200mg tab BID x 3 days, Leviteracetam 500mg tab OD

DIAGNOSTICS

CBC: Reference D0 D5

Hemoglobin 123-153 g/L 156 156

Hematocrit 0.36-0.45 % 0.48 0.48

RBC 4.5-5.1x1012/L 5.57 5.63

WBC 4.4 – 11.0 x 109/L 16.3 11.9

Neutrophils 0.55-0.70 0.79 0.62

Lymphocytes 0.25-0.40 0.10 0.26

Monocyte 0.03-0.10 0.10 0.10

Eosinophil 0.01-0.04 0.01 0.01

Basophil 0.00-0.01 0.01 0.01

Platelets 150-450x109/L 277 333

Reference Range D0 D4

RBS 123mg/dL

BUN 4.67-23.40 mg/dL 22.52

Creatinine 0.72-1.18 mg/dL 0.92

Sodium 135.0 – 148.0 mEq/L 138.2 138.7

Page 4 of 5
Potassium 3.50-5.30 mEq/L 4.45 4.19

CSF ANALYSIS

CSF Glucose 40-70 33.81 AFB stain no acid fast bacilli

no encapsulated
CSF Protein 15-45 73.90 India Ink
organism seen

PMN cells 0-3/LPF

pH 7.30-3.40 9.0 Culture no growh

transparency clear

specific gravity 1.008

WBC 0.073

RBC 0.001

segmenters -

lymphocytes -

monocytes -

eosinophils -

SARS COV 2 RTPCR: Negative

Blood CS: NO GROWH

Urinalysis
Macroscopic clear
Chemical pH 7.5 Specific Gravity 1.015 Sugar: negative
Protein: trace
Flow Cytometry Reference Range
Pus cells 0-3/HPF 0
Red Cells 0-2/HPF 0
Epithelial Cells 0-3/HPF 2
Bacteria 0-50/HPF 0

FINAL IMPRESSION:

BACTERIAL MENINGITIS

Page 5 of 5