3. HISTORY OF PRESENT ILLNESS
• (+) left ear pain
• (+) fever (undocumented)
• (+)decreased hearing after swimming in the beach
• took unrecalled eardrop, condition resolved in 3 days
4. HISTORY OF PRESENT ILLNESS
• (+) biparietal headache characterized as:
-dull, persistent with severity of 6-7/10
• (+) nausea and vomiting once a day consisting of
previously ingested food (non bloody)
• (-) fever (-) blurring of vision
• no consult done
• took Ibuprofen 200mg/cap 1 cap once daily with
partial relief
5. HISTORY OF PRESENT ILLNESS
• (+)persistence of headache, with similar
characteristics,
• (+)still with nausea and vomiting
• (+) fever tmax 38C associated with body malaise and
decreased appetite
• took Co-amoxiclav 1gm/tab 1 tab twice daily but no
relief of fever noted
• no consult done, patient tolerated the condition
6. HISTORY OF PRESENT ILLNESS
• (+) sudden onset jerky movements of all extremities
lasting for 30 seconds associated with upward rolling
of eyeballs.
• associated with undocumented fever, (+) neck
stiffness
• condition resolved spontaneously, patient was
immediately rushed to the ER
8. PERSONAL SOCIAL HISTORY
• student
• non smoker
• occassional alcoholic beverage
drinker
• no illicit drug use
9. SEXUAL HISTORY
• 1 sexual partner- current boyfriend of 1 year
(boyfriend also claims to be sexually exclusive with gf)
• no history of casual sexual encounters
• no history of STIs
10. FAMILY HISTORY
• Paternal- stroke, hypertension
• Maternal- DM
• no family history of epilepsy
• no history of sudden cardiac death
11. PHYSICAL EXAMINATION
• patient was examined drowsy and confused
Vital Signs:
BP 100/60mmHg
HR 83 bpm
RR 20 cpm
O2 95% RA
Temp 36.7
• Weight 50kg
• Height 157cm
• BMI 20.28
12. PHYSICAL EXAMINATION
• SKIN- warm, dry, good turgor, no rashes
• HEENT-
Head: normocephalic,
Eyes: pink conjunctiva, anicteric sclera, +PERRLA, (-) papilledema
Ears: (-) redness, (-) swelling, intact ear canal and tympanic membrane,
non tender upon palpation
Nose: nasal septum at midline, no sinus tenderness
Mouth: oral mucosa pink, good dentition, tonsilopharyngeal
walls not enlarged, dry lips and tongue
13. PHYSICAL EXAMINATION
• NECK- (-) neck vein distention, (-) LAD (+) neck rigidity ,
• Chest and lungs: equal chest expansion, clear breath sounds, (-)
wheezing
• Cardiovascular: adynamic precordium, regular, no murmurs, PMI at
5th ICS MCL
• Abdomen: flabby, no visible pulsations, normoactive bowel sounds,
no abdominal bruits, tympanitic , non tender
• Extremities: no edema, no ulcers, warm extremities; brachial, radial,
popliteal, dorsalis pedis, posterior tibial pulses are 2+ and symmetric,
no pulse deficit
14. NEURO EXAMINATION
• Handedness: Right
• Mental Status: Drowsy, oriented to person but not to place and time,
speech clear and fluent with normal comprehension,
• unable to recall what happened prior to admission,
• able to follow commands
15. II, III Visual fields full, isocoric pupils 4mm reactive to light
III, IV,
VI
EOM intact, no ptosis, no nystagmus
V Facial sensation equal in all 3 divisions bilaterally
VII Face symmetric with normal eye closure and smile
VIII Hearing normal to rubbing fingers
IX, X Phonation normal
XI Shrugs shoulders bilaterally with equal strength
XII Tongue midline with good movements
16. • Motor strength: Normal bulk, 5/5 right upper and lower extremities
and left lower extremity, 4/5 left upper extremity
• Sensory: 100% sensation on all extremities
• Reflexes: 2+ and symmetric with plantar reflexes downgoing
• Cerebellar: Rapid alternating movements, finger to nose test and heel
to shin test intact
• Gait: Steady with normal steps, base, arm swing, no pronator drift,
negative Romberg
18. SUMMARY OF IMPORTANT FINDINGS
• 20 yr old female
• history of ear infection
• (+) biparietal headache 6-7/10
• (+) nausea and vomiting for 2 weeks
• (+) moderate grade fever tmax 38C,
• (+) body malaise (+) dec appetite
• (+) new onset GTC seizure 1 day PTA
lasting for 30 sec
• (+) neck rigidity
• (-) papilledema
• (+) unable to recall what happened
prior to admission
• (+) drowsy
• (+) Brudzinski
• (+) Kernig
19. IMPRESSION
ACUTE
BACTERIAL
MENINGITIS
BASIS
• 20 years old
• history of ear infection
• (+) biparietal headache 6-7/10
• (+) nausea and vomiting for 2 weeks
• (+) moderate grade fever tmax 38C, (+)
body malaise (+) dec appetite
• (+) new onset GTC seizure 1 day PTA lasting
for 30 sec
• (+) nuchal rigidity
• (+) Brudzinski and Kernig sign
20. DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
1. ENCEPHALITIS - female of reproductive age
- headache 6-7/10
- fever of 1 week
- altered LOC- drowsy and confused
- signs of inc ICP: N&V, drowsy
- GTC seizures
Lumbar puncture to rule out
with PCR
2. BRAIN ABSCESS - history of ear infection
- headache 6-7/10
- fever of 1 week
- signs of inc ICP: N&V, drowsy
- seizures
imaging such as MRI to rule out
3. SUBARACHNOID HEMORRHAGE - headache 6-7/10
- signs of inc ICP: N&V, drowsy
- neck stiffness
imaging such as CT to rule out
27. •Admit under the service of IM
•TPR q 4 hrs
•Secure signed consent
•Vital signs q hourly
•NPO temporarily
•Transfer to isolation
•O2 at 2lpm via NC
•IV- PNSS 1L 20gtts/min
28. • Blood Culture
• Lumbar puncture, gram's stain and culture
• MRI with contrast
• EEG
29. • start empirical treatment stat with:
• ceftriaxone 2gm IV every 12 hours
• dexamethasone 10mg 1v 20 mins before first dose antibiotices then q6H
thereafter
• vancomycin 1.25gm IV every 12 hours
• acyclovir 500mg IV q8H
• give Valproic Acid (Depakene) 500mg/cap 1 cap twice daily
• elevate head of bed to 30-45 degrees
32. • give Ceftriaxone 2gm IV every 12 hours for 2 weeks
• dexamethasone 10mg IV 15-20 mins before first dose antibiotics,
then every 6 hours thereafter for 4 days
• repeat lumbar puncture after 24-36 hrs of antibiotics
• continue Valproic Acid (Depakene) 500mg/cap 1 cap twice daily
• monitor patient closely
