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Case Study 2

Morgan Millett, FNP-S

+Client/Source/CC

Patient is G.S, 23 year old G1 P0 Caucasian female

Source was office visit. Patient was 28 weeks pregnant, coming in for a problem visit.

Chief Complaint: “horrible headache.”

+History of Present Illness Patient is a 23 year old G1 P0 female who presented to

the office with complaints of a headache that started two days ago and had progressively gotten worse. She had taken 650mg of Tylenol q6 hours without any relief. Her pain was 9/10 on the numeric pain scale. She explains the headache as being posterior, pain directly above her neck, as well as above her ears bilaterally and throbbing. She had not been doing anything differently when she noticed the headache had started. She states pain becomes worse when she is lying flat. She denied vision changes, nausea/vomiting, and dizziness. She reports feeling chills, but had not checked her temperature at home. She denied contractions, leaking of fluid, and vaginal bleeding. + fetal movement.

+ What are we thinking ???

What was her daily caffeine intake? Could this be a caffeine headache?

Was she under any stress? Could this be a tension headache?

Did she have a history of high blood pressure? Could this be pre-eclampsia?

+Answers

Patient does not drink any caffeine at all. She has never been a coffee or soda drinker.

Patient stays at home and takes care of her house as her husband travels as an architect building bridges all over the U.S. She stated she didn’t have any lingering self or familial stress.

Patient does not have a history of high blood pressure. Her BP at this office visit was 110/58.

+Past Medical History

Patient had no relevant past medical history

She was a healthy woman, who has always had yearly physicals and GYN exams.

Her first trimester screening blood work was all normal.

Her glucose challenge test was normal.

+Social History

Stay at home wife

College degree in Business

Does not drink alcohol

Does not smoke or use illicit drugs

+Family History

Father:None

Mother: None

Only child

+Allergies & Medications

Allergies: She has no known drug allergies. She denies allergies to food, environment, and latex.

Medications:

Prenatal vitamins

+Review of Systems General: fatigue r/t not being able to rest from headache, chills.

Respiratory: Patient denied a history of respiratory infections, cough, recent chest xray, exposure to TB, difficulty breathing, wheezing, and night sweats.

HEENT: Denies dizziness, syncope, or head injuries. Patient denies lumps, swollen glands, and reports no limitations in ROM of the neck. Denies any ear pain, discharge, tinnitus, vertigo, or hearing changes. Reports photophobia but denies any pain, redness, tearing, discharge, burning, diplopia, or history of trauma.

Mouth/Throat: Patient denies taste disturbances, excessive dryness, and sore throats.

Cardiac: She denied hypertension, heart murmurs, chest pains, palpitations, and dyspnea. He denies edema, claudication, and varicose veins.

Gastrointestinal: She denies heartburn, nausea/vomiting, constipation/diarrhea, food intolerance, and changes in bowel patterns.

+ROS continued

Hematological: Patient denied unusually bleeding/bruising, history of anemia, and history of blood transfusions

Neuro/Musculoskeletal: Patient reports headache, slight neck pain/stiffness r/t headache. She denied back pain, paralysis, and deformities.

Psychiatric: Patient denied a history of anxiety and depression. She denied nightmares, insomnia and mood changes.

Endocrine: Patient denied thyroid problems, cold/heat intolerance, polydypsia, and polyuria

+Physical Exam General: Well developed, 23-year-old female who is

alert, oriented, and cooperative. FHR 145.

Vitals signs: T 100.9, BP 110/58, HR 90, R 20, O2 100% on room air. Height: 5’4” Weight: 165. BMI 28.3

HEENT:Patient able to distinguish sensation on face and able to puff cheeks, smile, frown, close eyes, and show teeth. No mastoid tenderness, or TMJ present. Neck is symmetrical, trachea midline, thyroid nonpalpable, ROM unlimited, no nuchal rigidity noted, no lymphadenopathy. Shoulder shurg without difficulty. Ears are symmetric, no pain or tenderness on palpation of the pinna or tragus

+Physical Exam Continued Boney landmarks present bilaterally, cone of light present at 5

o’clock on right and 7 o’clock on the left. Tympanic membrane is pearly grey bilaterally. Vibrations heard equally in both ears, can hear whispered word bilaterally and AC>BC bilaterally. PERRLA 4mm bilaterally. Snellen chart: OD 20/25, OS 20/25 OU 20/25, not corrected. Gross color perception intact. Peripheral fields intact by confrontation test. Cover/uncover test: fixed and steady gaze bilaterally. EOM’s intact. Corneal light reflex present bilaterally. Nasal opening patent in each nostril. Turbinates are grey and moist. Septum midline and not deviated. Good dentition, oral mucosa, hard and soft palate, and gums are pink and moist. No sores, masses, or ulcers seen on exam. Tongue is midline, patient repeats “ahhh” and pillars converge.

Thorax/Lungs: Respiratory rate is equal and regular.. Lungs are clear to auscultation in all lobes. No rales, rhonchi, or wheezes appreciated.

Cardiovascular: S1 and S2 present in APETM with bell and diaphragm. Regular apical rate. No heaves, thrills, murmurs, rubs, or gallops appreciated.

+Physical Exam Continued

Neuro: Patient is calm and cooperative, her speech is clear and she is oriented to person, place and time. Her memory is intact as she can repeat recite 5 spoken words, and recall a past event. Negative Romberg, her gait is smooth and steady. She is able to walk heel/toe without difficulty. She was able to identify light and sharp touch in bilateral forearms and calves. She was able to feel vibrations in her thumb and great toe without difficulty. Reflexes are 2+ in biceps, triceps, patellas, and Achilles, and the plantar reflex is intact.

+Assessment/Plan

Because the risk of developing preeclampsia is highest during a first pregnancy, patient went to L&D for preeclampsia work up.

CMP, CMP, LD & Uric acid

Clean catch urinalysis, protein/creatinine ratio

+Lab Results

WBC’s slightly elevated, CBC otherwise normal

CMP, LD & Uric acid normal

Urinalysis and P/C ratio normal

While patient was on L&D, her fever got progressively worse. She was admitted for observation. T max 102.4

+Differential Diagnosis

Preeclampsia (likely not r/t labs and BP)

Migraine??

Meningitis??

Encephalitis??

Systemic infection??

+Plan

At this point the patient was complaining of the worst headache of her life. She was requiring complete darkness in her room, and was sitting up in the bed, as lying down still made it worse.

Patient was requiring narcotics for pain which were not relieving her headache, as well as fioricet. She had no relief.

Neurology was consulted.

+Consult

History and physical were done by inpatient Neurology. The patient had no recent exposure to insects or animals, any contact with ill persons, recent travel, or preexisting medical conditions. Her neuro exam was benign.

CT scan was ordered to look for brain swelling, hemorrhage, or abscess which if present, could make a spinal tap unsafe.

Patient also had an MRI (which is now the imaging study of choice)

+Scan Results

MRI showed two low-density brain lesions, one at the base of the skull, and one in the temporal lobe with early involvement of white matter.

Neurosurgery was consulted to r/o brain tumor

+Lumbar Puncture

Neurology performed a lumbar puncture at the patient’s bedside for analysis of cerebrospinal fluid.

CSF analysis:

elevated WBC’s

Elevated RBC’s

Elevated protein

Decreased glucose

+Based on CSF results…

Neurology wanted to send the CSF for HSV-1 and HSV-2 polymerase chain reaction (PCR) study

PCR is highly sensitive (94-98%) and specific (98-100%). Results become positive within 24 hours of the onset of symptoms

+Diagnosis: Herpes Simplex Encephalitis (HSE) (054.3)

Herpes simplex encephalitis (HSE) is an acute or subacute illness that causes both general and focal signs of cerebral dysfunction. Brain infection is thought to occur by means of direct neuronal transmission of the virus from a peripheral site to the brain via the trigeminal or olfactory nerve. The exact pathogenesis is unclear, and factors that precipitate HSE are unknown.

+Background HSE represents a primary HSV infection in about one third

of cases; the remaining cases occur in patients with serologic evidence of preexisting HSV infection and are due to reactivation of a latent peripheral infection in the olfactory bulb or trigeminal ganglion or to reactivation of a latent infection in the brain itself.

HSE can have a sudden or insidious onset. The prodromal phase lasts 4 - 10 days during which the patient experiences non-specific symptoms (fever, malaise etc.) as well as headaches and personality changes. This may progress into a CNS catastrophe with seizures, visual defects, paresis, speech defects, behavioral changes, stupor and coma. CT/MRI scan may reveal low density abnormalities

+Incidence HSE is the most common non-epidemic encephalitis

and accounts for 5-10% of all cases of encephalitis.

The annual incidence of HSE is 0.2-0.4/100,000.

HSE is most common and severe in children and elderly people.

One third of patients are aged under 20 years and half are over 50 years at presentation.

HSV-1 encephalitis is more common in adults and and HSV-2 infection is more common in neonates.

+Clinical Manifestations Prodrome of malaise, fever, headache with light

sensitivity, nausea and vomiting.

This is followed by acute or subacute onset of:

Altered consciousness, focal and generalized seizures, features of raised intracranial pressure, including papilloedema, focal neurological signs, including hemiparesis and cranial nerve lesions.

Psychiatric symptoms, behavioral abnormalities, confusion and delirium. Hallucinations of taste and smell, amnesia, dysphasia and visual field loss.

+How is it diagnosed?

CT/MRI will show brain lesions

PCR + for HSV-1 and/or HSV-2

Brain Biopsy

+Treatment/Management Acyclovir 30/mg/kg/d IV for at least 10 days (up to 21

days) in adults

Start empiric acyclovir therapy promptly in patients with suspected HSE pending confirmation of the diagnosis because acyclovir is relatively nontoxic and because the prognosis for untreated HSE is poor.

Failure to consider the possibility of HSE can result in delayed diagnosis and treatment, with subsequent increased risks of mortality and morbidity.

+Outcome

Considerably improved because of the availability of acyclovir therapy and rapid PCR testing.

If not treated in a timely manner, patients may experience neurological deficits for the rest of their lives.

Thankfully, this patient did not have any neuro symptoms aside from her headache, and therefore did not have lasting damage despite the time it took to diagnose her.

+References:

Anderson, W. (2014). Herpes Simplex Encephalitis. Medscape. Retrieved from: http://emedicine.medscape.com/article/1165183-overview

Caliendo, A. (2013). PCR Testing for the Diagnosis of HSV in Patients with Encephalitis. UpToDate. Retrieved from: http://www.uptodate.com/contents/pcr-testing-for-the-diagnosis-of-herpes-simplex-virus-in-patients-with-encephalitis-or-meningitis

Raschilias, F. (2002). Outcome of and Prognostic Factors of HSE in Adult Patients. Clinical Infectious Disease, 35(3), 254-60.