** Reply to note from [log in to unmask] Thu, 18 Jun 1998 00:42:10 -0500
> It's July and you are seeing a 14 year old male with a 48 hour
> history of fever, emesis, worsening headache. PE notable for: T = 38.4, P
> = 100, RR = 24, BP = 100/70. He is alert, appears tired but non-toxic, and
> has photophobia and nuchal rigidity. Remainder of exam including full
> neuro assessment, perfusion, etc is entirely wnl.
> You suspect meningitis and have a high suspicion that it is of
> viral origin. How many would make a clinical diagnosis of viral meningitis
> and send him home (or admit if dehydration is a concern) without a lumbar
> puncture? If an LP is performed and results are consistent with an aseptic
> meningitis, would you send home? Admit and observe without antibiotics?
> Admit and begin Ceftriaxone while awaiting culture results? Admit and
> begin Ceftriaxone, Vancomycin, and corticosteroids while awaiting culture
When viral meningitis first started appearing here 2 weeks ago, I did 3 LPs in
one night. I have since done 2 more and have seen a couple of dozen people
who clinically had meningitis, mostly in the pediatric age group.
I base my decision whether to tap or not on how ill the patient appears
(decreased responsiveness to verbal stimulus in the older patient, marked
lethargy in younger ones, evidence of dehydration in all groups). If I tap, I
call the pediatrician or internist and recommend admission, leaving the
decision on whether or not to administer antibiotics to the admitting
physician. If I don't tap, I explain to the patient and/or the parent(s) that
the patient probably has viral meningitis in the context of the current
environment, that the course is unaffected by the administration of abx and
that they should come back in if symptoms worsen, then I dismiss them.
Mark in San Angelo
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