تمرين پزشكي باليني

Your Diagnosis,Please

A Previously healthy 40-year-old woman was admitted to the infectious ward. 50 days before admittion, she was evaluated in another hospital of fever, Nosea, Vomiting, headache, sweating and 10 kg. Weight loss. Her physician initiated for her, gentamycin, co- amoxyclar, Librium aretan, bethamethazone LA and ... 10 days before admittion to this hospital, she was referred to a psychological clinic with symptom and signs of major depression slow movements, introversion Brady kinesia and behavioral disturbances. Because of neck- stiffness fever and vertigo, an infectious disease consultant visited her, and for bilateral sixth nerve parasia, bilateral stage III pupil oedema and loss of consciousness the patient, was transmitted to infectious ward. Her husband is addict and consumes opium and has been in prison for a short time recently. Thereʹs no history otimmuno- suppressive drug consumption. A brain CT scan without contrast was performed and it was normal. A lumbar puncture was done. The pupils were reactive bilaterally with a normal fundoscopic examination. Mucous membranes were moist without oral lesions or thrush. There was no supraclavicular, inguinal cervical or axillary lymphadenopathies chest X. ray was performed and bilateral hilar lymphadenopathies were seen. Lung parenchymas were clear and costophrenic, and costodiaphragmatic angles were clear and sharp. Examination of heart demonstreated a regular simusal rhythm. The abdomen was non-tender with normal bowl sounds. A complete blood count (Hi) revealed a WBC count of 10400 with 80% PMN 10% lymphocytes Wo eosinophyl and 9% Monocytes. Urine analysis was normal. Febrile agglutination tests, Wright standard tube test, 2 ME, VDRL Vidal test were normal. Erythrocyte sedimentation rate for first hour was 1 15, PPD was positive with 15-mm induration. Sugar, urea nitrogen, creatinine, uric acid, LDL, HDL, Na, K, Ca, and P were examined and all tests were normal. Cultures of blood and urine showed no growth and CSF panel showed: protein 90 mg-dl sugar 30 mg/dl, WBC= 175 with 72%, PMN and 28% lymphocytes, a diagnostic procedure was then performed.