Clinical Course The next morning the patient woke up confuse

Clinical Course. The next morning, the patient woke up confused and disoriented, with mild tremors. His headache was also much worse. His wife drove him immediately to the urgent care clinic for evaluation. PMH. 18 months s/p cadaveric renal transplantation, ESRD secondary to DM type 1, diagnosed 10 years ago, CAD, asthma, DM diagnosed at age 13 Meds. Nitroglycerin 0.4mg SL PRN Theo-Dur 100mg PO BID Albuterol MDI 2 puffs QID PRN Atrovent MDI 2 puffs BID Cyclosporine 250mg PO BID Prednisone 10mg PO QD Mycophenolate mofetil 1500mg PO BID Insulin: NPH insulin 16 units at breakfast, Lispro insulin PRN Allergies. Vancomycin (rash), PCN (rash, hives, difficulty breathing), sulfa-containing products (rash) PE & Lab Tests. General. The patient is disoriented pale, is manifesting mild tremors, appears ill. VS. BP 150/95, HR 105, RR 17, T 100.5 Skin. warm & pale, no rash noted HEENT. PEERLA, EOM intact, fundi reveal old laser scar bilaterally w/o hemorrhages Neck. thyroid normal, supple, no masses present LN. cervical and axillary lymph nodes are palpable (approx. 2 cm) CV. PMI is normal, not displaced, S1 & S2 are normal; carotid, femoral, dorsalis pulses normal Chest. Lungs CTA bilaterally, full excursion of the chest without tenderness Abd. Soft, non-tender, without organomegaly; BS normal Rect. Heme-negative stool Ext. ROM intact Neuro. Disoriented, mild tremor in both hands, DTRs are 2+ bil for biceps, brachioradialis, quadriceps and Achilles, +Kernig sign, + Brudzinski sign, muscular strength 3/5 throughout, slightly decreased sensation to light touch in both feet (c/w diabetic neuropathy) MRI. Mild diffuse cerebral edema with no intra-cerebral bleeding Enzyme Immunoassay with Plaque Reduction Neutralization Test: + for West Nile

Question 3. Three of the drugs listed above are of particular concern in this patient. Pick TWO (2) drugs and explain why should they cause concern? (3 pts)

Question 4. What is suggested by the positive Kernig & Brudzinski signs? (2pts)

Question 5. Suggest a reasonable pathophysiologic explanation for the patient’s enlarged lymph nodes? (2pts)

Question 6. This patient has a Creatinine of 2.5. What could be a possible cause for this based on the patients medical history? (2pts)

Question 7. Based on all the available clinical evidence above, including the incubation period and geographic location of mosquito bite, what is a likely diagnosis for this patients’ condition? (2pts)

Solution

3. The drugs Theo-Dur and Albuterol causes Dizziness, headaches, light headedness. Atrovent will cause headache and eye pain.

4. Since the personal examination of the patient had pain when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee was also painful he was suggested to be positive for Kernig.

Since the patient had involuntary lifting of the legs when lifting the head it was suggested to be positive for Brudzinski sign.

5. The patient had enlarged lymph nodes due to West Nile virus transmission which is acquired through mosquito. Since the virus can pass the blood brain barrier and causes encephalititis.

6. Since the patient is on medication he has mild kidney damage due to which the patient had creatinine of 2.5

7. The likely diagnosis for the patients condition is West Nile virus infection.