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Headache, Weakness, and Dizziness

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A 21-year-old college student is brought to the emergency department (ED) by her roommate. The roommate states that earlier in the day the patient complained of a severe headache, stiff neck, and photophobia. On their way to the ED, the roommate states that she was confused. Her vital signs are blood pressure (BP) 110/80 mm Hg, heart rate (HR) 110 beats/minutes, respiration rate (RR) 16 breaths/minute, and temperature 102°F.

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What is the next step in the management of this patient?

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a. Start empiric antibiotics, order a noncontrast head computed tomography (CT) before performing lumbar puncture (LP)

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b. Order a noncontrast head CT and start antibiotics once CT is read by radiology

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c. Give 1 g of acetaminophen, start IV fluid hydration, and perform an LP

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d. Perform an LP and start antibiotics based on the cerebral spinal fluid (CSF) results

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e. Order a noncontrast head CT, perform an LP, then start antibiotics

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The answer is a. This patient presents with symptoms consistent with meningitis. Antibiotics are administered empirically as diagnostic workup proceeds. The best choice in this patient is ceftriaxone, which has good CNS penetration. In order to avoid transtentorial herniation in this patient with a neurologic deficit (confusion), a noncontrast head CT should be performed before LP. It is controversial whether or not a head CT needs to be performed before all LPs. However, if there is papilledema or a neurologic deficit, head CT is mandatory.

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It is not prudent to wait for results from a head CT before giving antibiotics (b). This will only delay treatment of a potentially fatal disease. Although this patient can benefit from acetaminophen and hydration (c), starting antibiotics empirically is more important. In addition, this patient requires a head CT before LP. As previously stated, antibiotics should be started early in management and not be delayed while waiting for results (d and e).

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A 21-year-old college student is brought to the emergency department (ED) by her roommate. The roommate states that earlier in the day the patient complained of a severe headache, stiff neck, and photophobia. On their way to the ED, the roommate states that she was confused. Her vital signs are blood pressure (BP) 110/80 mm Hg, heart rate (HR) 110 beats/minutes, respiration rate (RR) 16 breaths/minute, and temperature 102°F.

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The Gram stain of the patient's CSF reveals gram negative diplococci. Which of the following is true regarding postexposure chemoprophylaxis in this case?

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a. Given the specific pathogen, postexposure prophylaxis for ...

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