Wednesday, 26 March 2008

A Patient with Fever, Headache and Sore Throat

Dear Bloggers

Today, I bring you another most exciting case.

It is up to you to try and work out the diagnosis here.

A 70 year old male was see in another hospital's outpatient clinic with the following symptoms:

  1. Fever
  2. Headache
  3. Sore Throat
Fever: The above symptoms had started gradually three weeks before. The fever was observed by the patient to be about 37.5 degrees and with slight increase above this in the evenings. There were no rigors associated with the fevers.

Headache: The headache had also come on gradually and was located in the sides of the patient's head and also at the base of the skull at the back. The headache was worse when the patient combed his hair. There was no associated nausea, vomiting, neck stiffness or photophobia. The patient denied visual disturbance and there was no limb weakness described. There was no history of a 'thunder clap' severe headache and no visual aura's.

Sore throat: The sore throat also started at the same time. The patient had been to see a local doctor and inspection of the throat revealed redness but no exudate. No throat swab examination was taken. An upper respiratory infection was favoured, and a 3rd generation cephalosporin was prescribed on that basis but no resolution of symptoms was observed.
The patient's symptoms were becoming progressively worse and he was feeling increasingly tired and had observed a loss of 2kg in body weight.

On further questioning, the patient was also experiencing shoulder discomfort and had in fact been feeling tired for almost 6 months. Moreover, the patient also complained of a recent inability to fully open his mouth. Also, his taste had become impaired. There was also confirmation that there was some tongue pain whilst eating food.

Body Systems Review

The patient denied joint and muscle pain and she described no swelling, no skin rashes, no cough / sputum / dyspnoea / haemoptysis / night sweats. There were no cardiac symptoms such as chest pain or palpitations. There were no other gastrointestinal symptoms such as epigastric pain / vomiting / constipation / diarrhoea / jaundice / change in colour of stool + urine / haematemesis / haematochezia. The patient had no obvious neurological symptoms.

The patient was a non-smoker and there was no history of contact with tuberculosis.

Previous medical history included Hep C infection following vaccination as a child.
There were no other medical problems.

The patient was taking no medications and there were no known drug allergies.

The patient was retired and lived with his wife in a 3rd floor apartment. There was a working elevator which had never had problems. However, when asked, he considered that it might take him several minutes to walk up the several flights of stairs if the elevator was to break because of fatigue.

On examination

The patient looked chronically ill but was fully alert and conversant.

HEENT: His tongue was coated with a thick white covering which was confluent rather than patchy. The oral mucosa was not coated. The throat was mildly red with no exudate. The thyroid was normal size and non-tender. There were several lymph nodes below the mandible bilaterally which were mildly tender, smooth and mobile. They were <1cm>
There was conjunctival pallor but no scleral jaundice.

Hands revealed no peripheral signs of systemic disease.

CVS: pulses were all present. There was a tachycardia of 100/min regular. JVP was not raised.
Heart sounds were normal with no murmur and no added sounds. There was no leg oedema and no evidence of deep vein thrombosis.

RESP: RR- 18/min, Sats 98% on room air, trachea central, no tracheal tug, normal percussion note and normal breath sounds.

ABDO: Soft, non-tender, no masses, no organomegaly, normal bowel sounds. Rectal examination was normal and revealed no faecal occult blood.
There was no jaundice and no signs of chronic liver disease.

CNS: Cranial Nerves 2-12 were normal. Taste sensation was not checked. Fundoscopy was not performed.

PNS: No neck stiffness, Kernig's and Brudzinski's signs were negative. Jolt accentuatuation was negative. Tone, power, reflexes, coordination and sensation were within normal limits.

Musculoskeletal Examination revealed tender temporal and occipital areas on the cranium. There was full range of movement of the neck but generally tender. There was no joint pain or swelling and muscles were non-tender.

Skin Examination: There was no obvious skin abnormality.

Bloods: revealed a normocytic anaemia with a haemoglobin of 8g/dl. Platelets were slightly raised. White cell count was slightly elevated at 12.1 x10^9/L. Liver function tests were three times normal for AST and ALT. HCV PCR was positive. INR was 1.52. Renal function was normal.

Urine: normal.

Lumbar Puncture was performed revealing RCC 1600, WBC 23 (neutrophils 15, Lymphocytes 8), normal protein and glucose. Gram stain negative.

CXR: Normal

ECG: sinus tachycardia.


1) From just the history and physical examination, list the problems with this patient.

2) Was there any indication to do a lumbar puncture in this case? Were there any contraindications? What is your interpretation of the result?

3) What other tests would you like to perform on the day of admission?

4) What is your diagnosis? What one test will provide the definitive diagnosis here?

5) What treatment would you start and when? How long do you continue such therapy and what other considerations are necessary?

The answers to this fascinating case will be provide in the near future. Please send me your answers so that they can be placed on the answer page.

Happy sleuthing.... :-)

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