Case #15
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If you have completed case O, this is a review.
Completion of this case will not be counted toward your assignment.
Chief Complaint
John Smith, a 21-year-old white male college student,
presents to the Student Health Center at a large university just prior to
Spring final exams. As the physician staffing the Health Center you have
access to diagnostic x-ray machines and laboratory equipment to perform
common out-patient laboratories.
John complains of a severe, bi-frontal headache that began approximately
12 hours ago. He also notes feeling warm but neither he nor his roommate
have a thermometer.
- What are some common causes of
headache?
- What additional questions
should you ask the patient?
- Is the season of the year
important?
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Review of Symptoms
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John
has difficulty tolerating the bright lights of the examination room. He
admits to a stiff neck for the last 6 hours. He denies any rashes.
He has never been hospitalized and only other visit to the Student
Health Center was for a fractured right wrist that resulted from a
rollerblading accident 2 years prior.
He takes no prescription medications.
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- Why is the use of any
medication, including over the counter medications, pertinent?
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Social History
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John lives
in a high-rise dormitory with 3 roommates. He denies any sick contacts. He
denies any recent history of trauma and has not been rollerblading since
his fractured wrist 2 years ago.
He drinks about a six-pack of beer on Friday and Saturday nights. He
rarely drinks alcohol during the week. He smokes a ½ pack of cigarettes a
day. He used intravenous heroin for a brief period of time while in high
school. He denies any current illicit drug use excepting occasional
marijuana use at fraternity functions.
Physical Examination
His
temperature is 38.8°C (102.0°F), blood pressure 120/80 and heart rate
72/min. He is avoiding eye contact with the examination lights. Pupils are
equal and reactive with photophobia noted. No papilledema by
opthalmoscopic examination. Positive nuchal rigidity. No cervical
lymphadenopathy. Heart is regular with murmurs. Lungs are clear to
auscultation. Abdomen is soft, non-tender, with normactive bowel sounds.
There are no rashes. There is a positive Kernig’s sign.
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- What are Kernig’s and Brudzinsky’s signs?
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The patient is
awake and alert. His sensorium is clear. Cranial nerves are intact. Muscle
strength and sensation are intact. Deep tendon reflexes are 2+ and equal
bilaterally. Babinski signs are absent. Cerebellar testing is normal. |
- What is your differential diagnosis at this
time?
- What is the most appropriate first test?
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Test Results
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A lumbar
puncture is performed. The opening pressure is 100 mmHg. Normal values
range from 70 to 180 mmHg. |
- Is computed tomography of
the brain necessary before proceeding with lumbar puncture?
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Results from the lumbar puncture are listed below:
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Appearance
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Clear
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| Color
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Colorless
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| Nucleated Cells
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266
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| Cell Count Differential:
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| RBCs
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2%
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| Neutrophils
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36%
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| Lymphocytes
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57%
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| Monocytes
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7%
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- What additional tests should be obtained from
the spinal fluid?
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Additional
studies from the spinal fluid are obtained:
Glucose = 68 mg/dL Normal 45-80 mg/dL
Protein = 57 mg/dL Normal 15-45 mg/dL
Gram stain = Few polymorphonuclear cells, no organisms seen
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- What
additional laboratory tests would you
like to order?
- What
is the most likely etiology of this patient’s symptoms?
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John
was admitted to the hospital with the diagnosis of meningitis.
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- What organisms are common causes of
bacterial meningitis?
- What are the common cerebrospinal fluid findings in
patients with bacterial meningitis?
- What is the treatment of choice for
bacterial meningitis?
- If John had suffered from
bacterial meningitis, what steps should be taken to insure the
health of his close contacts?
- What is the most common etiology of
meningitis in the neonatal period?
- Which infectious etiology of meningitis should be
considered in all immunocompromised patients, especially after
organ transplantation?
- Given the patient’s history of
intravenous drug use in the past, what other infections is
this patient at increased risk of contracting that may result
in signs and symptoms of meningitis?
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In
this case, your patient’s HIV test was negative. The importance of
protected sexual intercourse and the avoidance of intravenous drug use was
stressed during his hospitalization. |
- If a patient were to suffer a generalized
tonic-clonic seizure after admission to the hospital with the
diagnosis of bacterial meningitis what complication would be
of particular concern?
- What electrolyte abnormality that commonly complicates
bacterial meningitis may provoke seizures?
- What are some common complications of bacterial
meningitis?
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