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Case Study 2
Morgan Millett, FNP-S
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Client/Source/CC
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Patient is G.S, 23 year old G1 P0 Caucasian female
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Source was office visit. Patient was 28 weeks pregnant,
coming in for a problem visit.
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Chief Complaint: “horrible headache.”
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History of Present Illness
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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.
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What are we thinking ???
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What was her daily caffeine intake?
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Was she under any stress?
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Could this be a caffeine headache?
Could this be a tension headache?
Did she have a history of high blood pressure?
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Could this be pre-eclampsia?
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Answers
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Patient does not drink any caffeine at all. She has never been
a coffee or soda drinker.
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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.
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Patient does not have a history of high blood pressure. Her
BP at this office visit was 110/58.
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Past Medical History
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Patient had no relevant past medical history
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She was a healthy woman, who has always had yearly
physicals and GYN exams.
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Her first trimester screening blood work was all normal.
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Her glucose challenge test was normal.
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Social History
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Stay at home wife
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College degree in Business
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Does not drink alcohol
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Does not smoke or use illicit drugs
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Family History
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Father:None
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Mother: None
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Only child
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Allergies & Medications
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Allergies: She has no known drug allergies. She denies
allergies to food, environment, and latex.
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Medications:
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Prenatal vitamins
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Review of Systems
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General: fatigue r/t not being able to rest from headache, chills.
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Respiratory: Patient denied a history of respiratory infections, cough,
recent chest xray, exposure to TB, difficulty breathing, wheezing, and
night sweats.
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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.
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Mouth/Throat: Patient denies taste disturbances, excessive dryness,
and sore throats.
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Cardiac: She denied hypertension, heart murmurs, chest pains,
palpitations, and dyspnea. He denies edema, claudication, and varicose
veins.
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Gastrointestinal: She denies heartburn, nausea/vomiting,
constipation/diarrhea, food intolerance, and changes in bowel patterns.
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ROS continued
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Hematological: Patient denied unusually bleeding/bruising,
history of anemia, and history of blood transfusions
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Neuro/Musculoskeletal: Patient reports headache, slight
neck pain/stiffness r/t headache. She denied back pain,
paralysis, and deformities.
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Psychiatric: Patient denied a history of anxiety and
depression. She denied nightmares, insomnia and mood
changes.
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Endocrine: Patient denied thyroid problems, cold/heat
intolerance, polydypsia, and polyuria
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Physical Exam
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General: Well developed, 23-year-old female who is alert,
oriented, and cooperative. FHR 145.
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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
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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
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Physical Exam Continued
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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.
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Thorax/Lungs: Respiratory rate is equal and regular.. Lungs are
clear to auscultation in all lobes. No rales, rhonchi, or wheezes
appreciated.
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Cardiovascular: S1 and S2 present in APETM with bell and
diaphragm. Regular apical rate. No heaves, thrills, murmurs, rubs,
or gallops appreciated.
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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.
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Assessment/Plan
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Because the risk of developing preeclampsia is highest
during a first pregnancy, patient went to L&D for
preeclampsia work up.
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CMP, CMP, LD & Uric acid
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Clean catch urinalysis, protein/creatinine ratio
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Lab Results
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WBC’s slightly elevated, CBC otherwise normal
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CMP, LD & Uric acid normal
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Urinalysis and P/C ratio normal
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While patient was on L&D, her fever got progressively worse.
She was admitted for observation. T max 102.4
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Differential Diagnosis
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Preeclampsia (likely not r/t labs and BP)
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Migraine??
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Meningitis??
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Encephalitis??
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Systemic infection??
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Plan
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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.
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Patient was requiring narcotics for pain which were not
relieving her headache, as well as fioricet. She had no relief.
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Neurology was consulted.
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Consult
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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.
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CT scan was ordered to look for brain swelling, hemorrhage,
or abscess which if present, could make a spinal tap unsafe.
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Patient also had an MRI (which is now the imaging study of
choice)
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Scan Results
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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.
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Neurosurgery was consulted to r/o brain tumor
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Lumbar Puncture
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Neurology performed a lumbar puncture at the patient’s
bedside for analysis of cerebrospinal fluid.
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CSF analysis:
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elevated WBC’s
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Elevated RBC’s
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Elevated protein
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Decreased glucose
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Based on CSF results…
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Neurology wanted to send the CSF for HSV-1 and HSV-2
polymerase chain reaction (PCR) study
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PCR is highly sensitive (94-98%) and specific (98-100%).
Results become positive within 24 hours of the onset of
symptoms
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Diagnosis: Herpes Simplex
Encephalitis (HSE) (054.3)
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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.
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Background
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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.
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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
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Incidence
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HSE is the most common non-epidemic encephalitis and
accounts for 5-10% of all cases of encephalitis.
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The annual incidence of HSE is 0.2-0.4/100,000.
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HSE is most common and severe in children and elderly
people.
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One third of patients are aged under 20 years and half are
over 50 years at presentation.
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HSV-1 encephalitis is more common in adults and and HSV-2
infection is more common in neonates.
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Clinical Manifestations
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Prodrome of malaise, fever, headache with light sensitivity,
nausea and vomiting.
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This is followed by acute or subacute onset of:
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Altered consciousness, focal and generalized seizures,
features of raised intracranial pressure, including
papilloedema, focal neurological signs, including
hemiparesis and cranial nerve lesions.
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Psychiatric symptoms, behavioral abnormalities, confusion
and delirium. Hallucinations of taste and smell, amnesia,
dysphasia and visual field loss.
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How is it diagnosed?
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CT/MRI will show brain lesions
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PCR + for HSV-1 and/or HSV-2
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Brain Biopsy
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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.
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Failure to consider the possibility of HSE can result in
delayed diagnosis and treatment, with subsequent increased
risks of mortality and morbidity.
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Outcome
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Considerably improved because of the availability of
acyclovir therapy and rapid PCR testing.
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If not treated in a timely manner, patients may experience
neurological deficits for the rest of their lives.
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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.
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References:
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Anderson, W. (2014). Herpes Simplex Encephalitis.
Medscape. Retrieved from:
http://emedicine.medscape.com/article/1165183-overview
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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-thediagnosis-of-herpes-simplex-virus-in-patients-withencephalitis-or-meningitis
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Raschilias, F. (2002). Outcome of and Prognostic Factors of
HSE in Adult Patients. Clinical Infectious Disease, 35(3), 25460.