Case Study #7   1  2  3  4  5  6  7  8  9  10  11  12  13   Travel and Infectious History Ten days before admission, the patient returned from 2 months of travel in Asia He prepared his own food, used only boiled water, and did not swim in any river or lake He was in his usual state of good health on return to the US He received Japanese encephalitis vaccine prior to the trip Outdoor cats at home, no scratches on patient No tick or mosquito bites and no sick contacts reported Japanese encephalitis usually demonstrates bilateral thalamic lesions, especially hemorrhage on MRI (Kumar S et al. Neuroradiology 39:180, 1997) Physical Exam afebrile, vital signs stable lethargic, but oriented to time and place no rash no facial asymmetry or focal neurologic deficits increased tone in the left leg but 5/5 strength in all extremities Babinski reflex downgoing, no Brudzinski’s sign no lymphadenopathy Admission Labs   Na+ 134 (135-145 mmol/L)   K+ 3.8 (3.5-4.5 mmol/L)   Cl- 98 (96-106 mmol/L)   C02 26 (22-30 mmol/L)   BUN 11 (8-18 mg/dL)   Cr 1 (0.5-1.2 mg/dL)   Ca ++ 8.8 (8.8-10.2 mg/dL)   Mg + + 3 (1.8-3.0 mg/dL)   PO4- 2.2 (3.1-4.5 mg/dL)         Phenytoin 9 (10-20 mg/mL)         WBC 7.1 (4-10K/mL)   Hb 15 (14-18 g/dL)   Hct 45 (40-52%)   PLT 265 (150-350K/mL)   Seg 76 (38-81%)   Lymph 14 (14-46%)   Mono 10 (2-15%)         Breakpoint #3 How would you proceed at this point?