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On physical examination the patient looks fit but

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On physical examination, the patient looks fit but fatigued, even a little sleepy. His temperature is 99.1degrees. His blood pressure is somewhat low, at 100 over 60, and his heart rate is elevated at 100 beatsper minute.Careful inspection shows a faint petechial rash on the trunk.The patient also has nuchal rigidity, mild sinus tenderness, and limited pharyngeal inflammation, but noexudates.On neurological examination, the patient is alert, but with a hint of early deterioration in concentrationability on the serial sevens test. Findings include meningeal irritation on the Brudzinski and Kernig tests.However, there are no other focal findings.Mental status change, fever, neck stiffness, and nuchal rigidity are common presenting findings inmeningitis. Usually, at least two of these signs are present. These signs, plus headache and rash on thetrunk or extremities, are suspicious for meningococcal meningitis in a college student or military recruitliving in an enclosed setting who is otherwise healthy. Symptoms usually occur 3 to 7 days afterexposure from close contact with an individual with a throat infection or respiratory secretions.Since the advent of the Haemophilus influenzae type b vaccine, the pneumococcal conjugate vaccine,and the quadrivalent meningococcal conjugate vaccine, the incidence of bacterial meningitis hasdeclined, especially in infants and children. But cases still occur because the vaccines do not cover allserotypes.Neisseria meningitidis accounts for 14 to 20% of meningitis cases.Predisposing factors include recent respiratory or ear infection, otorrhea or rhinorrhea, exposure to aninfected individual, immunocompromise, prior head trauma, and recent travel to sub-Saharan Africa.Skin examination is diagnostically significant in this patient. Meningococcal bacteremia can produce apink, red, or purple rash that can darken and enlarge into confluent bruises as infection progresses. Earlydiagnosis and treatment are critical to prevent rapid and fatal progression of infection.Downloaded from by MARITES CASTILLO BUSTAMANTE on 30 September 2021
Copyright © 2018 Wolters Kluwer. All rights reserved.Page 9Migraine.Migraine can be considered in the differential diagnosis of this patient, because of the stress of examsand his headache severity, nausea, photophobia, and stiff neck.However, he lacks several signs of migraine: a preceding aura with flashing lights or scotomata, which ispresent in 25% of cases; unilateral location; a pulsatile quality, and pain that increases with activity.The patient also has a fever, which is unusual in migraine.This is also his first headache, and most migraines are episodic, with occurrence fewer than 15 days amonth. Migraines usually begin in late childhood or adolescence, run in families, and are three timesmore common in adult women than in men. Common migraine triggers include stress, lights, andalcohol ingestion.

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Term
Fall
Professor
NoProfessor
Tags
Headache, Wolters Kluwer, CASTILLO BUSTAMANTE

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