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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • List risk factors and common presenting signs and symptoms of bacterial meningitis in infants and children.

  • Differentiate common bacterial pathogens associated with meningitis in children of different ages.

  • Recommend appropriate empiric and definitive antimicrobial and adjunctive therapy for bacterial meningitis.

  • Identify appropriate monitoring parameters for antimicrobial therapy of bacterial meningitis.

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PATIENT PRESENTATION

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Chief Complaint

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From mom: “Why is my baby so sleepy? And what is this purple rash?”

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HPI

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David St. Hubbins is a 2 yo, 13.6 kg male toddler who presented to the emergency department with his mother. Mom reports that she noticed him sleeping longer than normal since yesterday evening after returning from daycare, as well as this morning. She also reports that he had a poorer than normal appetite at dinner and breakfast. She also notes the rapid appearance of a purplish rash on his extremities, trunk, and back. At 08:00 she checked his temperature, reporting a temperature of 39.1°C. At this point, the mother reports that she called her sister who is a nurse, and was told to go straight to the emergency room. When aroused prior to transport, David was irritable and frequently crying. She indicates that during transport, David was in and out of sleep and did not respond well to normal stimuli. There was one episode of slight vomiting during transit.

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PMH

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David was born via an uncomplicated vaginal delivery at 39 weeks. Mother reports one episode of otitis media at 13 months of age, treated with amoxicillin.

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FH

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Mother is in good health; father has hypercholesterolemia; maternal grandparents both with metabolic syndrome; paternal grandfather in good health; maternal grandmother alive, history of breast cancer.

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SH

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Lives with mother and father. Father is a rock musician and mother is a teacher. David began attending daycare 3 months ago. Father is a smoker. No pets in the home.

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Meds

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None; immunizations up to date per the U.S. CDC Advisory Committee for Immunization Practices (ACIP)

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All

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NKDA

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Review of Systems

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Refer to HPI

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Physical Examination

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Gen
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Lethargic toddler with generalized rash in mild-moderate distress

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VS
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SBP 75, HR 152, RR 48, T 39.4°C; Wt 13.6 kg, SatO2 (RA): 98%

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HEENT
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PERRLA, tympanic membranes erythematous bilaterally

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Chest
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Lungs clear bilaterally

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CV
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Sinus tachycardia, regular rhythm, no murmurs, rubs, gallops

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Abd
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