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  #1  
Old 01-21-2012
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Neuro Next best step in management of meningitis

A 45 year old man comes to the emergency department with fever, headache, photophobia and stiff neck. What is the best next step in management?

A- Lumbar puncture
B- Head CT
C- Ceftriaxon and vancomycin
D- Penicillin
E- Movement of the patient to ICU
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  #2  
Old 01-22-2012
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LP + ATB...so I think IŽll go with A)
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Old 01-23-2012
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Default I'd go with treatment

C. Never delay meningitis treatment if the suspicion is really HIGH. You can give first dose of antibiotics and then do LP, do fundoscopy before LP (or CT) to rule out masses in CNS which would contraindicate LP.
I think both LP and treatment are right but you shouldn't delay any treatment while awaiting a test or results.
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Old 01-23-2012
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Originally Posted by dr_mhm View Post
C. Never delay meningitis treatment if the suspicion is really HIGH. You can give first dose of antibiotics and then do LP, do fundoscopy before LP (or CT) to rule out masses in CNS which would contraindicate LP.
I think both LP and treatment are right but you shouldn't delay any treatment while awaiting a test or results.
Yeap...but you should do the LP first and then give the ATB...you dont have to wait for the results though, but this patient doesnt have any contraindication for LP...
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Old 01-23-2012
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Originally Posted by bebix View Post
Yeap...but you should do the LP first and then give the ATB...you dont have to wait for the results though, but this patient doesnt have any contraindication for LP...
Tricky one..., I guess you could go both ways, if you actually do the LP right away.
So, what's the answer?
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  #6  
Old 01-23-2012
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Thanks UptoDate (I love it, hahaha)
19.3

"Avoidance of delay — Antibiotic therapy, along with adjunctive dexamethasone when indicated, should be initiated immediately after the performance of the lumbar puncture (LP) or, if a computed tomography (CT) scan of the head is to be performed before LP, immediately after blood cultures are obtained"

so, I guess is A)
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  #7  
Old 01-24-2012
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If no ct indicated (like in this case)- LP then ABx
If CT indicated, ABx, then CT, then LP
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Old 01-24-2012
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I tthought CT should be performed so we can see if endocranial pressure is elevated...otherwise it could be dangerous..Why CT is not important in thiw case?
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Old 01-25-2012
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Originally Posted by MANIAKOS View Post
I tthought CT should be performed so we can see if endocranial pressure is elevated...otherwise it could be dangerous..Why CT is not important in thiw case?
Infectious Diseases Society of America (IDSA) guidelines for the management of bacterial meningitis:

A CT scan of the head before LP should be performed in adult patients with suspected bacterial meningitis who have one or more of the following risk factors:

1- Immunocompromised state (eg, HIV infection, immunosuppressive therapy, solid organ or hematopoietic stem cell transplantation)
2- History of CNS disease (mass lesion, stroke, or focal infection)
3- New onset seizure (within one week of presentation)
4- Papilledema
5- Abnormal level of consciousness
6- Focal neurologic deficit
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