Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in the Emergency Department. Your next patient is an 18-year-old female, Jolyne Cujoh, presenting with a fever. Please take a history and perform an appropriate examination.
Patient History:
Jolyne Cujohn, an 18-year-old female student.
Since a few days ago, you have been feeling unwell with shivering. Last night, you took your temperature, and it was 38.5 degrees C! You haven't had a fever since a long time, so this is something out of the ordinary. You have taken two paracetamol tablets, which helped settle the fever.
For the past few days, you have always felt tired with muscle aches all around the body. You do feel nauseous, but no vomiting. You currently have a low appetite and are not drinking as much fluid as you would have liked. You constantly have this headache all around your head – it feels like a pressure squeezing your head. This is, however, not of concern to you as this is only mild and goes away after taking a few painkillers. Everything seems to be getting worse.
If asked specifically, your neck feels stiff. You also feel more sensitive to bright lights – you always want to keep yourself in a dark room and avoid lights when possible. You also noticed a few red rashes starting to appear around your arms and legs.
Waterwork normal. Bowel Normal. No SOB. No cough. No seizures. No altered consciousness. No hearing loss. No abnormal sensation or weakness. No confusion. You are unaware of the vaccinations you had as a child.
Ideas, Concerns, Expectations:
You have no idea what is going on, but you think you might have an infection of some sort. You are concerned as things don't seem quite right. You would like to go home with some antibiotics.
Past Medical History:
T1DM
Drug History:
Insulin - Basal Bolus Regime
NKDA
Family History:
Nil
Social History:
You are currently a first-year medical student studying Medicine. You just started moving into the university last week. You cannot wait to become a doctor just like the doctor seeing you.
You don't normally drink alcohol, but you went out quite a few times lately to meet new people and had a few "jager bombs" - yuck!
You do not smoke.
You live in an accommodation with other students.
Examination Findings:
Well-orientated.
Wide-spread non-blanching erythematous rash affecting upper and lower extremities.
Cold Hands. CRT > 2 seconds.
Neck and upper back rigidity.
Kernig's test positive.
Brudzinski's test positive.
Does not tolerate fundoscope examination
Neurological exam is otherwise normal – normal tone, power, reflex, and sensations.
No neurological deficits. No cranial nerve dysfunction.
Differentials:
Bacterial meningitis and Meningococcal Septicaemia - outlined by high fever, headache and risk factors. Septicaemia due to non-blanching rash.
Viral Meningitis - Usually less severe and may have viral-like symptoms
Fungal Meningitis - No immunodeficiency risk factors
Cerebral Abscess - No recent infection/risk factors, no focal deficit.
Encephalitis - Unlikely as of yet due to no focal/neurological deficit elicited
Rule out Infection or sepsis of other origin
Rule out Disseminated Intravascular Coagulation
Investigations:
Bedside:
Urine Dip/MSU
Nasopharyngeal swab Culture/ PCR
Stool Culture / PCR
Observations
Bloods:
Blood Culture, FBC, CRP, U&Es, LFTs, Bone Profile, Coagulation screen (DIC), blood gas
Meningococcal and pneumococcal PCR
Serum glucose to compare with CSF glucose
Consider serum syphilis screen/ cryptococcal antigen
Consider serum HIV
Consider serum procalcitonin (PCT) to differentiate bacteria cause from other causes e.g. viral.
Imaging:
Consider CXR (other pathologies for pyrexia)
Consider CT/MRI to rule out other underlying causes and complications such as mastoiditis / raised intracranial pressure/brain abscess, tumour, brain infarction, cerebral oedema, hydrocephalus...etc.
Special Test:
Lumbar Puncture with culture, microscopy, sensitivities, gram stain, viral/bacteria PCR, cell count, protein, lactate, and glucose.
Data Interpretation of Blood Tests:
| Value | Reference Range |
Hb | 125 g/L | 115 - 165 g/L |
White Cell Count | 19.8 x10^9/L | 3.6 - 11.0 x10^9/L |
Platelets | 350 x10^9/L | 140 - 400 x10^9/L |
Haematocrit | 0.50 x10^12/L | 0.40 - 0.54 x10^12/L |
MCV | 94 fL | 80 - 100 fL |
Neutrophils | 16 x10^9/L | 1 - 7.5 x10^9/L |
Monocytes | 0.7 x10^9/L | 0.2 - 0.8 x10^9/L |
Lymphocytes | 3 x10^9/L | 1 - 4 x10^9/L |
Basophils | 0.03 x10^9/L | 0.02 - 0.1 |
Eosinophils | 0.1 | 0.1 - 0.4 |
| | |
CRP | 166 mg/L | < 5 mg/L |
Interpretation of blood results
Management: