30 yo femal fever and headache

[pbruss]

I love EKGs if you look close they can tell you alot about a paitent. SOme of you in the ER already saw this case so dont spoil it.

30 yo femal, smokes, no ohter past medical history. for past week she has fever, body aches, fatigue, malaise, headahce and dizziness. gradual onset. nothing makes it worse or better. no sick contacts, no recent travel. denies etoh or drugs of abuse.

on exam hr120. temp 38.9. resp rate, bp, o2 st allnormal.

pleasent 30 yo femal, well dressed well nourished sitting in bed in no distress.
heart tachy
lungs normal
abd normal
ext normal
neuro - normal strenght sensation and reflex. lateral nystagmus, potisive rhomberg and ataxic gait.

attahced is he EKH form this visit and her previous EKG.

based on her history, exam and any change in her ekg what would you do next?

a. CT head
b. CTA chest
c. MRI brain
d. cardiac echo
e. CTA carotids
d. LP
F. MRI C-spine

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[kemple]

I'm going with LP thinking this is an acute viral cerebellar ataxia caused by a virus. I think that with her risk for mass effect being low combined with the hx a CT Brain wouldn't be as useful. I see some poor R wave progression on EKG compared to the previous and some slurring of the S waves. Additionally the P waves are more prominent. I couldn't find much except sometimes acute HIV can have the poor R wave progression.

[Bjs04f]

Interesting. Ive heard recently of a few drugs that cause this pattern, and she consistently shows some RsR' in AVR, but the new one also shows QT prolongation which could be drug induced. One is methoxphenydine or something sounding similar. They get cerebellar infarct presentation. Agree with dan do the LP ensure its not infectious, then prepare to get supportive. Supposedly its similar to Ketamin, but worse and easier to abuse

[pbruss]

its not LP. you guys are on right tract with EKG interp namely when dan says P waves are more prominent. what lead are the P waves prominant or different then previous EKG? waht does that tell you about her heart? How can that info explain her symptoms and exam? What test would be most usefull in confirming that connection?

[pbruss]

its not LP. you guys are on right tract with EKG interp namely when dan says P waves are more prominent. what lead are the P waves prominant or different then previous EKG? waht does that tell you about her heart? How can that info explain her symptoms and exam? What test would be most usefull in confirming that connection?

[pbruss]

its not LP. you guys are on right tract with EKG interp namely when dan says P waves are more prominent. what lead are the P waves prominant or different then previous EKG? waht does that tell you about her heart? How can that info explain her symptoms and exam? What test would be most usefull in confirming that connection?

[kemple]

So p waves larger in inferior leads could mean RAE, combined with posterior circulation issues needs echo. Could be viral myocarditis.

[pbruss]

exactly, the answer I was looking for was MRI but i think ech would be equally usefull. attached is her mri. she had an abscess in the cerebellum and pultiple enhancing lesion in the gray white area of the brain

[pbruss]

sorry here is the MRIs. and her ekg. like dan said the pwaves show both left and right atrial enlargment from vegitations. the mitral valve was the issue which is reflected by the new biphasic p waves in V1. the p vaes in 2 3 avf reflect right atrial enlagrment and to the mitral regerg cause by the vegitations.

Attachments:

[kemple]

Any reason as to why she has the brain abscesses?

[pbruss]

She was throwing septic emboli from her heart and one got hold and formed an abscess