Module 5 Case Study - Meningitis Flashcards

Admitting Diagnosis: Meningitis, not otherwise specified

Discharge Diagnosis: Viral Meningitis

History of Present Illness:

The patient is a young boy who presents with fever of 101, headache, photophobia, and vomiting. Two days prior to admission, he developed fever in the morning that progressed to a headache. On the following evening, he had increased p.o. intake. He had never had any prior headaches. He denied neck stiffness, rashes, and mental status changes. He had positive mosquito bites, but no tick bites. He was seen at a local clinic and was found to have a positive rapid strep test. Otherwise, no sick contacts and no recent travel were reported. A lumbar puncture was performed in the emergency room, showing 159 white cells but no red cells. The cerebrospinal fluid showed protein of 24 and glucose of 81. CBC had a white blood cell count of 11.6, hemoglobin was 13, hematocrit 36, platelets 235 with 73 segs, 11 bands, and 12 lymphocytes.

Past Medical History:

Asthma comes and goes with infectious triggers; diagnosed at 6 months. Pulmicort was taken this fall as well as albuterol, both via nebulizer. No hospitalizations or surgeries. Immunizations are up-to-date. Development is small for his age, but otherwise, he is on target developmentally.

Birth History:

Full term. Delivered vaginally; no neonatal intensive care unit (NICU) stay.

Social History:

He lives with mother, father, and a 9-year-old sister. He has three cats at home.

Family History:

Asthma on his father s side.

Review of Systems:

As per history of present illness.

Admitting Physical Examination:

Temperature 100.7, pulse 94, respiratory rate 24, blood pressure 106/52, weight 22.5 kg, length 119 cm. General appropriate, in no apparent distress, comfortable. Skin warm, dry, no rashes or lesions. HEENT showed head was mesocephalic, atraumatic. Pupils equal, round, reactive to light. Extraocular muscles are intact. Mucous membranes are moist and pink. Tympanic membranes are clear bilaterally. Neck has no lymphadenopathy; mildly increased stiffness with flexion. Chest is clear to auscultation bilaterally. Cardiac reveals a regular rate and rhythm, 2/6 systolic ejection murmur greatest at the left sternal border. Pulses are 2+ bilaterally. Abdomen is soft, nontender, and nondistended. Normoactive bowel sounds. Genitalia normal; external genitalia circumcised. Testes descended bilaterally. Musculoskeletal shows no joint stiffness and full range of motion in extremities. There is no lymphadenopathy. Neurologic exam is grossly intact with no focal deficits and no asymmetry.

Hospital Course:

On admission IV fluids were started. Pain medications were started as well as Tylenol and were to be titrated as needed. Enterovirus PCR from CSF was sent. His headache and photophobia continued over the course of the first 24 hours. Otherwise, he was afebrile. His p.o. intake was improving. Urine output was good. Enterovirus PCR came back positive. Culture showed no growth for 28 hours. Since he was doing well clinically, he was discharged home with his parents.

Condition at Discharge:

Stable.

Discharge Medications:

None.

Discharge Activity:

As tolerated.

Discharge Diet:

As before.

Follow-Up:

He is to schedule an appointment with his pediatrician within the week after discharge.

© Lippincott Williams & Wilkins

Lumbar puncture

Asthma

Viral meningitis.

True

False