The University of Arizona College of Medicine – Phoenix
Phoenix, AZ USA
History of Present Illness
A 59-year-old man was brought to our emergency department at 0300 with a possible stroke. He was last known well at 2230 the previous evening, when he complained of severe headache and took some acetaminophen before going to bed. His wife (who provided all history) noted that the patient awoke about midnight, vomited and took some naproxen. The wife next heard the patient awake at 0230, and found him back in the bathroom vomiting again, slow to respond, “mumbling” and confused. The wife was able to get the patient into their car with some difficulty and drove him to the ER.
Past Medical History, Social History, Family History
Only minimal past medical history was elicited. There was no known trauma, no fever and no recent illnesses. The patient took no prescription medications. He did not have any history of neurological disease or of substance abuse.
Physical Examination
Vitals from the ER at 0300 included: BP 157/130 mmHg, HR 101 bpm, RR 16 bpm, temperature 97.7°F.
The patient was described as “non-toxic appearing.” His eyes were open, but he was mute and didn’t obey commands. His Glascow Coma Scale was E4, V1, M5. Formal strength testing wasn’t performed, but he was observed to spontaneously move his arms. No facial asymmetry was noted.
Hospital Course
A “Stroke alert” was called based on the clinical presentation. The laboratory evaluation was significant for: WBCC 14.9x109/L, hemoglobin 13.2 g/L, platelets 181x109/L; Na 135 mmol/L, K 4.0 mmol/L, Cl 100 mmol/L, CO2 23 mmol/L, BUN 14 mg/dL, creatinine 0.7 mg/dL, glucose 349 mg/dL and INR 1.0. A procalcitonin was elevated at 0.8 ng/mL. Urinalysis showed >500 mg/dL glucose, moderate leukocyte esterase, WBCC 19/hpf, and no bacteria. A urine drugs of abuse screen was negative. CT head, CTA head/neck and brain perfusion scans were all negative for acute abnormalities. A virtual stroke neurologist recommended against lytics and/or thrombectomy, due to the lack of radiographic evidence of a large vessel occlusion.
The patient was admitted to the family medicine service. Ceftriaxone 1gm was administered for a presumed urinary tract infection. His temperature was retaken at 0630, at which time it had risen to 102.7°F. At 0730 the patient became agitated, diaphoretic and his SpO2 fell to 79%. His BP was 223/139 mmHg, HR 115 bpm, and RR 53 bpm and he was emergently intubated and transferred to the ICU.
Which of the following is false regarding the clinical findings of community-acquired bacterial meningitis? (Click on the correct answer to be directed to the second of 5 pages)