Past Medical History Type 2 DM diagnosed 1 year ago Stroke at age 60, no residual neurologic deficits Seizure disorder following stroke Depression diagnosed at age 62 following the death of her husband Family History Father had CAD, deceased from MI at age 72. Mother had diabetes and osteoporosis and died of “old age.” She had one brother who was killed in car accident at age 16. She had a daughter healthy sofar Social History The patient living with her daughter following stroke at age 60. The daughter reports that she is independent in her daily livings, including taking her medications, and is quite active. She is a retired homemaker. Tobacco/Alcohol/Substance Abuse: Unable to assess due to the patient’s mental status; no known tobacco or illicit drug use. Allergies/Intolerances/Adverse Drug Events: Morphine (itching) Medications Inpatient: Naloxone 2 mg IV × 1 administered on arrival (no response), Flumazenil 0.2 mg IV × 1 administered on arrival (no response), 0.9% sodium chloride IV at 125 mL/h Home: Aspirin 81 mg PO daily, Phenytoin ER 300 mg PO at bedtime, Sertraline 50 mg PO daily in the morning, Diphenhydramine 25 mg PO at bedtime Review of Systems: Unable to attain secondary to the patient’s condition Physical Examination General: Unresponsive, ill-appearing elderly female in acute distress Vital Signs: BP 88/62 mm Hg, P 122, RR 20, T 38.8°C, Weight 63.6 kg, Height 165.1cm, Unable to report pain Skin: Reduced skin turgor HEENT: PERRLA; TMs grossly normal Neck and Lymph Nodes: (+) Nuchal rigidity; (−) Kernig’s sign; (−) Brudzinski’s sign Chest: Clear to auscultation bilaterally Breasts: Examination deferred Cardiovascular: Sinus tachycardia Abdomen: Nontender; nondistended; no organomegaly Neurology: Normal DTRs; (+) corneal, gag, and cough reflexes Genitourinary: Examination deferred Rectal: Examination deferred Laboratory Tests: Obtained in ED All are in the normal range except: Glucose: 220 mg/dL CSF Analysis: WBC: 6.3 *103 cells/mL WBC differential: monocytes: 12% PMNs: 80% Lymphocytes: 8% Protein: 120 mg/dL Glucose: 66 mg/dL Cultures Blood cultures × 2: Pending Diagnosis: Sixty-seven-year-old female with signs, symptoms, and laboratory tests consistent with bacterial meningitis QUESTIONS Which symptoms in this patient’s history suggests the diagnosis of bacterial meningitis? What do this patient’s CSF findings indicate? What in this patient’s history may indicate the causative organism of bacterial meningitis? What empiric antibiotic therapy is indicated for this patient? For how long? What route(s) of antibiotic administration is(are) appropriate in bacterial meningitis? What are the monitoring parameters for this patient?
PATIENT PRESENTATION
Chief Complaint
The patient is currently unresponsive. Somnolence and “talking out of her head.”
History of Present Illness
Ruth Assefa is a 67-year-old female resident of Addis Ababa, Yeka Sub City who presents to the Emergency Department of Tikur Anbessa Specialized Hospital with a 3-day history of worsening confusion and somnolence. Prior to her delirium, she also complained of headache and stiff neck. None of her friends/families have reported any signs or symptoms of illness, but her 10-year-old grandson who visited last week was recently diagnosed with pneumonia. She has a history of seizure disorder and one of her friends reported that she may have had some seizure-like activity yesterday.
Past Medical History
Type 2 DM diagnosed 1 year ago
Stroke at age 60, no residual neurologic deficits
Seizure disorder following stroke
Depression diagnosed at age 62 following the death of her husband
Family History
Father had CAD, deceased from MI at age 72. Mother had diabetes and osteoporosis and died of “old age.” She had one brother who was killed in car accident at age 16. She had a daughter healthy sofar
Social History
The patient living with her daughter following stroke at age 60. The daughter reports that she is independent in her daily livings, including taking her medications, and is quite active. She is a retired homemaker.
Tobacco/Alcohol/Substance Abuse: Unable to assess due to the patient’s mental status; no known tobacco or illicit drug use.
Allergies/Intolerances/Adverse Drug Events: Morphine (itching)
Medications
Inpatient: Naloxone 2 mg IV × 1 administered on arrival (no response), Flumazenil 0.2 mg IV × 1 administered on arrival (no response), 0.9% sodium chloride IV at 125 mL/h
Home: Aspirin 81 mg PO daily, Phenytoin ER 300 mg PO at bedtime, Sertraline 50 mg PO daily in the morning, Diphenhydramine 25 mg PO at bedtime
Review of Systems: Unable to attain secondary to the patient’s condition
Physical Examination
General: Unresponsive, ill-appearing elderly female in acute distress
Vital Signs: BP 88/62 mm Hg, P 122, RR 20, T 38.8°C, Weight 63.6 kg, Height 165.1cm, Unable to report pain
Skin: Reduced skin turgor
HEENT: PERRLA; TMs grossly normal
Neck and Lymph Nodes: (+) Nuchal rigidity; (−) Kernig’s sign; (−) Brudzinski’s sign
Chest: Clear to auscultation bilaterally
Breasts: Examination deferred
Cardiovascular: Sinus tachycardia
Abdomen: Nontender; nondistended; no organomegaly
Neurology: Normal DTRs; (+) corneal, gag, and cough reflexes
Genitourinary: Examination deferred
Rectal: Examination deferred
Laboratory Tests:
Obtained in ED
All are in the normal range except:
Glucose: 220 mg/dL
CSF Analysis:
WBC: 6.3 *103 cells/mL
WBC differential:
monocytes: 12%
PMNs: 80%
Lymphocytes: 8%
Protein: 120 mg/dL
Glucose: 66 mg/dL
Cultures
Blood cultures × 2: Pending
Diagnosis: Sixty-seven-year-old female with signs, symptoms, and laboratory tests consistent with bacterial meningitis
QUESTIONS
- Which symptoms in this patient’s history suggests the diagnosis of bacterial meningitis?
- What do this patient’s CSF findings indicate?
- What in this patient’s history may indicate the causative organism of bacterial meningitis?
- What empiric antibiotic therapy is indicated for this patient? For how long?
- What route(s) of antibiotic administration is(are) appropriate in bacterial meningitis?
- What are the monitoring parameters for this patient?
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