A New Case For November

Dear Bloggers

I thought I would try and test your diagnostic skills with the following anonymised case.

A 75 year old lady was admitted from her home having fallen and being found in a collapsed state.

She was unable to remember what had happened although when found, she was confused and febrile.

She denied tongue biting, urinary incontinence, headache, neck stiffness, photophobia, visual disturbance, dizziness, chest pain, palpitations, dyspnoea, cough sputum, haemoptysis, urinary symptoms, musculoskeletal pains or skin problems.

Previous medical history included atrial fibrillation, gastric ulceration, hypertension, aortic stenosis and mild renal failure.

She was taking digoxin 125mcg/day, warfarin 3mg/day, lansoprazole 15mg/day and ramipril 5mg/day.

There was no family history of note and she was a non-smoker and non-drinker. She had a relatively active life and lived alone and independently.

On Examination

She was febrile 37.4 degrees C
Conscious level - mildly confused: date - wrong, time of day - wrong, person - correct. GCS 15/15

Generally - looked mildly unwell. No JACCOL.

HEENT - no obvious abnormalities or trauma

CVS: Pulse 80/min irregularly irregular, BP 124/78mmHg, JVP not raised. No heaves or thrills. Levine 2/6 aortic ejection systolic murmur heard best over the right parasternal border in the 2nd intercostal space with radiation to the carotid arteries and best heard with the patient sitting forwards and breathing in expiration.
There were normal peripheral pulses and no differences in quality of pulses on either side. Blood pressures of her arms and legs were approximately equal in respect of systolic and diastolic pressures.
No splinter haemorrhages, no Janeway Lesions, no Osler Nodes or conjuctival haemorrhage were notes.

RESP: Respiratory Rate 14/min, SpO2 95% breathing ambient room air, trachea central, expansion equal bilaterally, percussion note resonant and breath sounds vesicular with no wheeze or crackles.

ABDO: Soft, non-tender, no masses, no hepatosplenomegaly, no renal angle tenderness, no ascites, no distension of the bladder. Bowel sounds were normal and no bruits were identified. Rectal examination showed no evidence of bleeding.

CNS:
II- pupils equal and reactive to light, consensual response + and normal accommodation. Visual fields grossly normal.
III / IV / VI -Extra-ocular movements normal.
V - Motor and Sensory normal.
VII - Normal
VIII - Normal for her age
IX / X / XI/ XII - No focal abnormality

PNS:
Tone: Normal throughout
Power: Normal power MMT 5/5 in all 4 limbs
Reflexes: All present and normal in all 4 limbs
Coordination: Normal
Sensation: Normal throughout
Gait: Not tested.

Mini-Mental Test Score: 8/10

The Admitting Resident took this skull Xray in view of the confusion and fall to look for fractures.



Blood cultures revealed chains of streptococci in 4 bottles.

Questions:

1) What does the Skull Xray show?

2) How will you try to work out the cause of the abnormality?

3) What could be the cause of the positive blood cultures?

4) How will you determine the predisposing cause?

Advice: Some of these questions are tricky and the answer may not be exactly what you think it is...... Have fun ! Please send me your answers!!