Meningitis : Long Case

CONTENTS

1. History
2. Examination
3. Summary
4. List of problems
5. Management plan
6. Possible questions that could be asked during the discussion 

Meningitis is one of the commonest long case topics. It is more commonly given in Pediatrics than in Medicine. The format includes the history, examination, summary, list of problems and management.  First, a proper history should be taken.

HISTORY

• Introduction of the patient
• Name
• Sex
• Age
• From
• Occupation
• History is taken from .................... who is educated up to .................. and the history is reliable
• Presenting Complaint

The typical presentation of a child with meningitis is fever with drowsiness. As usual, first the presenting complaint should be written with the duration.

• History of presenting complaint

History of presenting complaint should start from the last time where the child was OK. Then the the sequence of event should be told like a story. Make sure to mention all the medications the child was given as well. Each and every presenting symptom should be analyzed thoroughly. For example, if we take fever, the following aspects should be asked.

• Onset
• Is it intermittent, remitent or persistent
• The time it takes for the fever to rise up to the maximum level
• How long the fever stays at its peak
• How long does it takes the fever to settle down
• How many fever spikes a day
• Does the fever responds to paracetamol
• Presence of any associated symptoms? (arthralgia, myalgia, chills and rigors)
• Nausea, vomiting
• Associated skin rash 

Meningitis is common among infants and it cause a lot damage to the developing brain. Therefore, whenever an infant comes with fever, meningitis lies high in the list, because it should be identified and treated as soon as possible to minimize the damage to the brain.

If the parents say that the child is drowsy, describe the level of consciousness according to the parents. After analyzing the presenting symptoms, the next thing is to have a list of differential diagnosis. A child can have fever with altered level of consciousness for several reasons. They are,

1. Encephalitis
2. Meningitis
3. Drugs
4. Electrolyte imbalances
5. Dehydration
6. Hypoglycemia
7. Seizures
8. Toxins
9. Delirium due to high fever

The analysis of the presenting symptoms may give a clue to the diagnosis, but you will have to ask specific questions to find specific symptoms that could support the diagnosis. If the child is having meningitis, he will have other features of meningitis such as photophobia and phonophobia. They might have associated nausea, vomiting, etc. If the child have severely altered conscious level, he is more likely to have encephalitis more than meningitis. 

Then you will have to ask questions to exclude or confirm other above mentioned differential diagnoses. Ask whether the child has access to any drugs. If the child has vomited or has had severe diarrhea, he can be having electrolyte imbalances. Ask about level of hydration. Also inquire whether the parents have noticed any abnormal movements in the child's body. Toxins are also a common cause of altered level of consciousness, so ask about the presence of toxins in the house. Sometimes the fever itself can cause altered level of consciousness. Therefore, ask whether the child had very high fever. 

In the history, you should ask things that could affect your management. If the child is having meningitis he can have increased intracranial pressure as a complication. If the child is having increased intracranial pressure, lumbar puncture cannot be done to obtain cerebrospinal fluid. Therefore, you should ask for features of increased intracranial pressure such as nausea, vomiting, etc.

Inquire about all other systemic symptoms to exclude or to confirm the diagnosis. Then complete other parts of the history.

• Past medical history

Specifically ask about seizures and febrile fits. 

• Birth history
• Surgical history
• History of head injury
• Allergic history
• Immunization history
• Development
• Family history
• family history of fits
• Social history 
• Dietary history

Examination

General examination

Since the child is having fever, a thorough head to feet examination should be carried out to find out whether there is any septic focus. 

• Temperature
• Ear discharge
• Skin rashes 
• seen in meningococcal meningitis
• Neck stiffness - Meningitis is inflammation of the meninges. When the neck is flexed the inflammed meninges are stretched, causing pain. So, the child will have pain when you bent his neck anteriorly. In very little children neck stiffness is not present, therefore meningitis cannot be excluded with absence of neck stiffness. 
• Kernig's sign - This also checks the presence of meningial inflammation. The child is kept in the supine position. Then his hip is flexed slowly with fully flexed knees. When the hip is fully flexed, the knee is slowly extended. If the child feels pain when the knee is extended, the kernig's sing is said to be positive. 
• Also check the hydration level of the child by looking at the capillary refill time. 
• BCG scar

Cardiovascular System Examination

Do a thorough cardiovascular system examination to find out the features of septicemia such as tachycardia, hypotention, etc.

Respiratory System Examination

• Tachypnea
• Features of respiratory tract infection - respiratory tract is one of the commonest sites of spread of organisms to the blood. 

Nervous System Examination

• Especially check the fundi for papilloedema to find out the presence of increased intracranial pressure.
• Look for features of focal neurological signs. 

Abdominal Examination

Abdominal examination may reveal hepatosplenomegally due to septicemia in meningitis. 

SUMMARY

The summary should include the most important parts of the history and examination. Important positive and negative findings should be included in the summary. Usually a summary should not be longer than 4 to 5 sentenses.

PROBLEM LIST

The aim of taking a history and examination is to formulate a comprehensive list of problems. Identify your patient's problems and categorize them as follows. Formulation of a comprehensive list of problems is the key to successful management of your patient.

• Medical Problems 
• Acute problems
• Chronic problems
• Psychological Problems
• Social Problems

MANAGEMENT

Address each and every problem in your problem list, through your management plan. Form a list of investigations that you would like to perform for your patient. Be prepared to justify why you are doing each and every investigation in your list. During the presentation of the case, make sure to mention the investigations along with reasons to do them before the examiner ask you.

• Cerebrospinal Fluid analysis (full report and culture) - to find out the etiological organism. 
• CT scan of the brain to visualize the changes and to exclude increased intracranial pressure.
• Full blood count to see the signs of infections. If there is a bacterial infection, there will be neutrophil lekocytosis. If there is a viral infection, there will be lymphocytic leukocytosis. 
• Blood culture
• Random blood sugar to see whether the child is hypoglycemic
• Serum electrolytes to see whether there is any electrolyte imbalances that might have given rise to altered level of consciousness.

DISCUSSION

Possible questions during discussion are,

1. How do you manage this patient?
2. How do you perform lumbar puncture in this patient?
3. What are the contraindications for lumbar puncture?
• Cardiopulmonary instability
• Focal neurological signs
• Signs of increased intracranial pressure (high blood pressure, bradycardia, coma)
• Coagulapathy
• Thrombocytopenia
• Local infection at the site of lumbar puncture
4. What are the things that you are going to look for in a CSF analysis report?
5. How do you diagnose the type of organism by the CSF report?
6. What are the features of CSF report in a partial treated meningitis?
7. What are the organisms that can be the cause of meningitis in this child?
8. How do you calculate the fluid requirement of the child? The child is not given all the fluid required because he is at risk of developing syndrome of inappropriate ADH (SIADH) secretion. So, he will be given only 2/3 rd of his fluid requirement.
9. What are the antibiotics you are going to give him? How long?
10. What is the role of dexamethosane in meningitis?
11. How do you assess the patient during daily ward round?
12. How do you give prophylaxis for contacts of a patient with meningococcal meningitis?
13. What are the complications of meningitis?