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Page - 25yo man, hx B cell ALL, ?seizure, now w/ AMS Please come to bedside
Admitted w/diarrhea & GI graft vs host disease
h/o ALL, multiple relapses including leptomeninges now in remission
What further information do you need? What are your 1st thoughts about what's going on?
Admitted w/diarrhea & GI graft vs host disease
h/o ALL, multiple relapses including leptomeninges now in remission
What further information do you need? What are your 1st thoughts about what's going on?
See image for details of event and vital signs
Medications: tacrolimus, infliximab, remicade
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Medications: tacrolimus, infliximab, remicade
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Based on information so far, which of the following is most likely correct regarding the event you were paged for?
Comments regarding localization and other teaching appreciated!
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Comments regarding localization and other teaching appreciated!
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Examination 1/2
General: chronically ill appearing
HEENT: Moist mucous membranes
Neck: supple, no meningismus
CV: RRR, no m/g/r
Lungs: CTAB, no wheezes, rales or rhonci
Abdomen: soft, nontender, nl bowel sounds.
Ext: mild B pedal edema, stable livedo-like rash on legs
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General: chronically ill appearing
HEENT: Moist mucous membranes
Neck: supple, no meningismus
CV: RRR, no m/g/r
Lungs: CTAB, no wheezes, rales or rhonci
Abdomen: soft, nontender, nl bowel sounds.
Ext: mild B pedal edema, stable livedo-like rash on legs
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Examination 2/2
MS: Sleepy, oriented to hospital, unsure why he is in the hospital. Unable to say days of the week backwards. Cannot name “thumb” but can name elbow and wrist, can follow 1-step commands but has some difficulty with 2-step
CN, Motor, Sensory, Reflexes normal
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MS: Sleepy, oriented to hospital, unsure why he is in the hospital. Unable to say days of the week backwards. Cannot name “thumb” but can name elbow and wrist, can follow 1-step commands but has some difficulty with 2-step
CN, Motor, Sensory, Reflexes normal
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Days of the week backwards is a good simple test of attention. What other tests are your favorite for testing attention in a confused patient?
Is his examination focal or nonfocal?
Is his examination focal or nonfocal?
Labs:
Hb: 6.5 / Hct 18.7 / WBC 11.9 / Plt 69
Neutrophils 73.0% / Lymphs 1.0 / Monos 6.0 / Bands 17.0
Na: 145 / K 3.9 / Cl 104 / HCO3 25 / BUN 37 / Cr 0.47
ALT: 42 / AST: 45 / Alk Phos: 117 / Tbili: 2.0 / Dbili: 1.2 / Albumin 2.6
Glucose: 144
PT: 12.4 / INR 0.9
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Hb: 6.5 / Hct 18.7 / WBC 11.9 / Plt 69
Neutrophils 73.0% / Lymphs 1.0 / Monos 6.0 / Bands 17.0
Na: 145 / K 3.9 / Cl 104 / HCO3 25 / BUN 37 / Cr 0.47
ALT: 42 / AST: 45 / Alk Phos: 117 / Tbili: 2.0 / Dbili: 1.2 / Albumin 2.6
Glucose: 144
PT: 12.4 / INR 0.9
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What treatment would you provide at this point?
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CT head
Would you do a lumbar puncture now?
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MRI results - no enhancement, no restricted diffusion
If no contraindications, in the setting of possible cancer and immunosuppression, and possible infection, I would do the LP.
Protein: 25.5
Glucose 113
RBCs: 172 in tube 1, 1 in tube 4
Nucleated cells: 1 in tube 1, 1 in tube 4
Opening pressure: 21cm H2O
Fluid appearance: clear
Protein: 25.5
Glucose 113
RBCs: 172 in tube 1, 1 in tube 4
Nucleated cells: 1 in tube 1, 1 in tube 4
Opening pressure: 21cm H2O
Fluid appearance: clear
What is the diagnosis?
Teaching on management appreciated too!
Teaching on management appreciated too!
