CASE NO.

1
CASE HISTORY:
R.T. 18 months old male form Dasmarinas, Cavite was admitted for the first time at DLSUMC because of fever and convulsions.
Review of history
The patient was having productive cough and colds since 1week prior to consultation associated with colds, with whitish discharge. He
was playful and with fair appetite. He woke up at night because of coughing episodes.
This condition persisted until 5 days PTA he started to have fever, on and off ranging from 38-39 degrees centrigrade. He was also less
active with fair appetite. He was given by the mother paracetamol 5 ml every 4 hours which afforded temporary relief of fever. Two
days PTA he was noted to be sleeping most of the time and had poor appetite. He drunk only fruit juices. Few hours PTA, he was seen
by the mother to have blank stare, then went into generalized tonic seizures which lasted for 5 mins. Thus brought to the ER.
QUESTION: WHAT ADDITIONAL INFORMATION WILL YOU ASK THE INFORMANT
PHYSICAL EXAMINATION:
At the ER the patient was drowsy with the following vital signs:
BP: 100/70 HR: 89/min RR: 45/min T: 39.5C
ABW: 12 kg
SHEENT: with small open full anterior fontanel; light yellow nasal discharge; wet ear canal, both sides, no jaundice; with inflamed
nasopharynx, (+) nuchal rigidity; (+) alar flaring, with multiple cervical lymphadenopathy
Chest & Lungs : (+) intercostal retractions; Harsh breath sounds; with crepitant rales on both lung fields, no wheezes
Heart: Distinct Regular Cardiac rhythm, no murmur
Abdomen: Liver and spleen not palpable, normoactive bowel sound, flat abdomen.
Extremities:No rashes, pale nail beds, full pulses.
NEUROLOGIC EXAM:
Patient is asleep but opens eyes when talked to then goes back to sleep again, incomprehensible verbal output, localizes to pain
Cranial Nerve Exam: Equally briskly reactive pupils with good direct and consensual light reflexes, preferential downward gaze with
some limitation of the lateral gaze, (+) decreased venous pulsations on fundoscopy, no facial asymmetry, can swallow, tongue midline.
Motor and Sensory: moves all extremities equally and localizes to painful tactile stimulation.
Meningeals: positive kernigs and brudzinsky.
Cerebellars: no nystagmus
DTRs: +++ in the biceps, triceps and exaggerated knee jerk.
Bilateral Babinski and sustained ankle clonus.
QUESTIONS:
1.

Are there anything in the history and physical / neurologic examination that you would like to ask more? Why?

2.

Can you give me at least 5 differential diagnosis and give the basis for such.

3.
What pertinent laboratory exams would you ask for? Please enumerate based on the order of importance. Give the indications
for such tests.
4.

Please explain the neurologic findings. Can you try to localize where the lesion is?

5.

Can you give the exact Glasgow coma scale of the patient?

6.

What is your primary impression and basis for the impression

MENINGITIS
7.

Give you plan of management

8.

Can you look for the best evidence to explain any of your diagnostic or therapeutic plan.