Meanwhile back at St.Elsewhere it is a busy night in the ER. In this fiction piece we have Neuprex just being approved for Meningo. It is in stock and you are up to date on Neuprex's possible uses besides Meningo. The following cases bombard you in rapid succession and the question is whether or not to initiate Neuprex in any or all of the cases along with any other appropriate therapy you deem necessary. Good luck.
Case 1
A 25-year-old woman, previously in good health, developed fever, chills, arthralgias, and a fine macular rash over her lower extremities. The following day the rash progressed over her trunk and upper extremities, and became purpuric. The patient developed severe headache and weakness. She was brought to the hospital by ambulance. The patient lived in Minneapolis and had not traveled outside the state in recent months. She had no pets or exposure to animals or ticks. She did not use alcohol, tobacco, or illicit drugs. Her last menstrual period was two weeks earlier. She took no medications regularly, and had no known allergies.
On examination her temperature was 101.7 degrees F and her blood pressure was 70/50 with a pulse of 140 beats per minute and respirations of 24 per minute. Mental status was clear. There was no meningismus. There was a diffuse purpuric rash over her body. There was no evidence of abdominal surgery. The rest of the physical exam was unremarkable.
Initial laboratory findings included Hb 12.3, WBC 2.5 (65% PMN, 25% bands), platelet count 64,000, Na 135, K 3.4, Cl 103, CO2 10, ABG (4L O2), pH 7.38, pO2 140, pCO2 24. Urine could not be obtained for analysis.
Case 2
A 22-year-old male noted pain in his left knee after playing a game of basketball. He took some ibuprofen that night but the pain progressively worsened. The next morning the knee was swollen and red, and the patient had a temperature of 102 degrees F. He went to see his family physician for further evaluation. The patient was otherwise healthy, took no chronic medications, and had no known allergies.
On examination, he had a temperature of 101.8 degrees F and otherwise normal vital signs. The left knee was swollen, red, and tender. There was marked tenderness in the knee with weight-bearing or range of motion.
Case 3
A 43-year-old man had facial pain and purulent nasal discharge for several days. On the day of admission to the hospital he left work early because of a severe headache. When his wife came home in the evening, she found him in bed, lethargic and feverish. He was brought to the hospital by ambulance and admitted to the intensive case unit.
On admission his temperature was 103 degrees F, and blood pressure was 100/60. He responded only to administration of a painful stimulus. He had no rash. There was no evidence of head trauma or recent surgical procedures. No papilledema was seen on fundoscopic examination. Heart, lung, and abdominal exam were unremarkable. No focal neurological deficits were detected.
Case 4
A 56-year-old man was hospitalized with a two-day history of high fevers to greater than 102 degrees F and diffuse superficial back pain. Prior to the onset of fever, he had no acute illness and had no history of chronic medical problems except for mild hypertension. On the day of admission he was also noted by his wife to have periods of confusion and difficulty speaking.
On admission, his temperature was 101 degrees F. Heart, lung, and abdomen exam were undreadable, and his neck was supple. There were no focal neurologic deficits. Admission labs showed a WBC count of 15,000 with 30% bands. CXR and EKG were normal.
In the next six hours, the patience developed hemorrhagic skin lesions on his abdomen and extremities. He became blind in both eyes and was noted to have a loud systolic murmur. |
