At 12:42 AM 6/18/98 -0500, you wrote:
> A hypothetical case which should generate some interesting
> 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
> Does anyone know of a cost/benefit analysis assessing each of the
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>The following case was not mine. It was 1980 and therefore only
partially pertinent to your hypothetical; i.e. no resistant pneumo,
steroids to prevent deafness not in vogue, no H. flu B vaccine
and just beginning to think of Lyme disease.
A 3 year old with no antecedent illness developed neck pain and T = 38.
It was in August and enteroviral illness was widespread in the community.
The attending doc tapped him and found 120 lymphs, no segs, normal glucose
and protein. Gram smear neg. Child appeared happy, sat up in bed, ate and
watched TV cartoons. Analgesics were prescribed and the child was observed
overnight. The following day the CSF grew out Flu B and the child was
treated with amp and chloro. Temp became normal within 24 hours, the
neck pain subsided, CSF became sterile within 24 hrs. and the child was
dischrged shortly thereafter.
Only one problem: the child developed a profound bilateral VIII n.
deafness - I mean cold stone deaf.
A malpractice case ensued with a judgement in favor of the plaintiff
for "delay in diagnosis".
I present this real case as an example that during the summer all
fevers are not Coxsackie and that bacterial illness does exist. Complacency
can get you a heap of trouble. The heck with the cost/benefit ratio!
Bob Schwartz, M.D.
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