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CPC Case for July 30, 2004

Discussant: Dr. Connie Chen
Presenter: Dr. Nilam Soni

CC

Change in mental status
HPI

A 22 -year-old man from Sudan with no significant past medical history was brought to the Presbyterian Hospital emergency room after an episode of syncope.  While sitting in his English class, the patient slumped over and had a decreased level of consciousness.  The episode lasted 1-2 minutes, and he was brought to the ER by his classmates.  In the emergency room, the patient was confused and combative, and was given haloperidol for sedation. 
A classmate recalled the patient complaining of worsening headaches over the past several weeks, and a few episodes of feeling like the room was spinning.  Also, he had complained of lower back pain for the past 5 months.  He denied fever, chills, night sweats, visual changes, convulsions, nausea/vomiting, chest pain, cough, palpitations, and abdominal pain.  

MEDICATIONS
  1. Over-the-counter pain medication for lower back pain
ALLERGIES No known drug allergies
PMH
  1. Appendectomy
  2. Malaria (1995)
FH The patient denies any medical problems in his parents or siblings.

SH

 He is a political refugee from Sudan who has been in the United States for 3 months.  He lived in Egypt for 2 years prior to coming to the United States.  He smokes approximately 10 cigarettes per day, but denies any alcohol or intravenous drug use. The patient is single.
ROS

 
PHYSICAL EXAM:

Vitals:  Temp 98.9, Pulse 140,  BP 150/71,  R22,  SaO2 98 

Gen: African man in no acute distress, well-developed well-nourished

HEENT:   Normocephalic, atraumatic. Pupils are equal, round, and reactive to light.

Neck:  No JVD, lymphadenopathy, or meningismus

Chest: Clear to auscultation bilaterally, except for few rales in left base

Cardiac: Regular rate and rhythm. No murmurs, rubs, or gallops

Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds

Extremities: No edema or cyanosis.

Neurological: Alert and oriented times three. Cranial nerves II-XII intact. No focal neurologic deficits.
LABS:
Na
149
K
 4.3
Cl
 102
HCO3
 15
Glu
 117
BUN
 11
                   
Creat
 0.9
Note: anion gap resolved within 24 hours
Alk Phos
 87
AST
22
ALT
17
TP
9.4
Alb
 17
Total Bili
0.2
Glob
 4.6
 
 
 
 
 
   
 
 
 
 
 
Trop I
<0.1
CK
89
CKMB
 1.8
 
 
 
PT
15.4
INR
 1.3
 
 
 
 
WBC
 13.700
Hgb
 14
Hct
 47
Plts
 723.000
 
 
Differential
  
N
 65%
L
 16%
M
 10%
E
 8%
 
ASA
 <5
APAP
 <1
 
 
 
Urine Tox
negative
Imaging and Other Studies
pCXR
 Questionable left lower lobe infiltrate
EKG
 Sinus tachycardia
CT Brain
 Small areas of altered density in the subcortical white matter of the right temporal lobe, right brachium pontis, and cerebellar vermis. 
MRI Brain
Multiple intracranial nodular and ring-enhancing masses scattered throughout both cerebral hemispheres, as well as within the cerebellum bilaterally and the right cerebellar white matter adjacent to the fourth ventricle.  There is some surrounding edema and local mass effect but no shift of midline structures.
MRI Lumbar Spine
 Lumbar Spine:  Marked edema and enhancement of T11-T12 disk space.  A large fluid collection is seen involving the left psoas muscle extending from T11-T12 into the patient’s pelvis. 
EEG
 None
  A diagnostic procedure was done and a diagnosis was made.