Who you are:
You are a F2 in general medicine.Who the patient is:
Peter, aged 27, came to the hospital with a headache.What you should do:
Take a focused history, assess the patient, do examination and discuss further management with the patient.
P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: On the back of my head.
D: When did it start? (onset)
P: 3 days ago.
D: Was it continuous or comes and goes?
P: It is continuous.
D: What type of pain is it? (character)
P: Dull.
D: Does the pain go anywhere else? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: Yes, light seems to make it worse. (+ve finding)
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain at all and 10 being the most severe pain you have ever experienced. (score)
P:6.
D: Apart from the headache, is there anything else you want to discuss with me today?
(concern)
P: No.
DDs
D: So, you said when you look at light, the headache gets worse? (Meningitis, SAH)
P: Yes, light makes it worse. (+ve finding)
D: Any neck stiffness? (Meningitis, SAH)
P: Yes (+ve finding)
D: Any rash on your body? (Meningitis)
P: Yes, I actually noticed I have a rash whilst I was coming here. (+ve finding)
D: By any chance have you had any fits? (Meningitis)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: No.
D: Any muscle stiffness or weakness? (PMR)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
D: Have you come in contact with anyone who has any infection?
P: No, I don’t think so.
+FLAWS
IF PATIENT HAS HIGH FEVER= (+ve finding)
P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: DM (Ask further)
D: Any other medical conditions like HTN, migraines and kidney disease?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is good.
D: Do you do physical exercise?
P: Sometimes yes.
D: Have you recently travelled out of the UK?
P: (Some African countries)
D: Have you around with someone, who had similar symptoms?
P: No
D: Did you come in contact after you got sick?
P: Girlfriend (Address in management)
Don’t forget ICE
Examination
- Vital signs - Full physical - rash
- Neurological - GCS, Brudzinski and Kernig signs
- Examine rash (If +ve): Glass test- to see blanching
Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that you have a headache that gets worse with light, and you have a fever and a rash, so I suspect you may have meningitis. It is an infection of the protective membranes that surround the brain and spinal cord.
Management
People with suspected meningitis will usually need to have tests in hospital and need to stay in hospital for treatment.
Call ambulance to send pt to the Hospital.
At GP can give IM Benzyl Penicillin.
Admit:
→ Treatment in hospital is recommended in all cases of bacterial meningitis and severe viral meningitis, as the condition can cause serious problems and requires close monitoring. For a few days, and in certain cases, treatment may be needed for several weeks.
→ Isolate and inform infection control.
Senior- Inform
Investigations:
→ Tests in hospital: Several tests may be carried out to confirm the diagnosis and check whether the condition is the result of a viral or bacterial infection.
→These tests may include: a blood test (routine + culture) to check for bacteria or viruses.
→ To confirm: PCR test by meningococcal
→ Other tests: Inflammatory markers (CRP), Clotting factors, blood culture
→ A lumbar puncture – where a sample of fluid is taken from the spine and checked for bacteria or viruses
→ CT scan to check for any problems with the brain, such as swelling
Symptomatic: As bacterial meningitis can be very serious, treatment with antibiotics, given directly into a vein, will usually start before the diagnosis is confirmed and will be stopped later on if tests show the condition is being caused by a virus.
→Morphine & PCM for pain
→ Fluids given directly into a vein to prevent dehydration.
→ Oxygen through a face mask if there are any breathing difficulties.
→ Steroid medication to help reduce any swelling around the brain, in some cases.
→ Additional treatment and long-term support may also be required if any complications of meningitis occur, such as hearing loss.
Preventing the spread of infection:
→ Notifiable disease- Contact tracing (Girlfriend needs prophylaxis)
→ The risk of someone with meningitis spreading the infection to others is generally low, but if someone is thought to be at high risk of infection, they may be given a dose of antibiotics as a precautionary measure.
→This may include anyone who’s been in prolonged close contact with someone who developed meningitis, such as:
- people living in the same house.
- pupils sharing a dormitory.
- university students sharing a hall of residence.
- a boyfriend or girlfriend.
- People who have only had brief contact with someone who developed meningitis will not usually need to take antibiotics.
Treatment of mild viral meningitis:
→ You’ll usually be able to go home from hospital.
→ This type of meningitis will normally get better on its own without causing any serious problems.
→ Most people feel better within 7 to 10 days. In the meantime, it can help to
- get plenty of rest
- take painkillers for a headache or general aches.
- take anti-sickness medicine for any vomiting.
Safety netting- Not necessary as patient will be admitted.