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Discussion

Pathphys argument

Okay, not an argument, really, but we're working on a group project and one member is sticking with a different answer from the rest of us. That's totally fine by us, it won't affect the grade. But I'm having trouble understanding the reasoning.

A 20-year-old college rugby player is brought in to the ER. During a match, he took a hit. He was slow to get up and his neck is stiff. The headache is much worse. His left hand is now numb and cold. His team mates say he just isn't acting like himself so they brought him in. His roommate says he overslept, was acting kind of sluggish before the game, and complained of a headache, but blamed it on over indulging at a party in the dorms the night before. While waiting for the results of the lumbar puncture, he begins seizing.

An assessment gives the following results:

temp 39.5 C

resting heart rate 110 beats per minute

respiratory rate 30 breaths per minute

X-rays - negative for skull fracture

negative for cervical vertebrae fracture

hyporeflexia

Left hand is pale and cold to the touch.

CSF analysis:

pressure 210 mm H20

color turbid

proteins 49 mg/ dl

glucose 42 mg/dl

WBC's 580/mm3

We say meningitis, probably bacterial. The WBCs alone indicate wicked infection, but add the pressure, turbidity, seizure, and behavior BEFORE the hit and we see infectious disease, rather than trauma. That's leaving out the cold, pale hand (perfusion issue due to septicemia, we suspect). I can't remember if brain trauma can affect resp rates or not, but I suspect it can, so that and heart rate aren't necessarily indications of infection vs trauma. But there's enough *other* stuff... I guess it just seems fairly clear-cut to the rest of us. I love that she's sticking to her guns, though. TBI was actually my first thought, but when I reread the question, there were more clues pointing to infection than trauma that I changed my mind.

I'm not looking for your agreement so much as more understanding of her POV. Would anyone else say TBI instead of meningitis? Why or why not?

Thanks! I'm so loving this class, I can't stand it, even though it's kicking my butt. :chuckle

Featured Replies

Starting out with the v.s., I would tend to suspect sepsis. Elevated T, HR and RR all support this theory.

With increased ICP due to a head injury, you would expect to see depressed RR and HR, along with a widening pulse pressure (although this scenario doesn't include a B/P.)

The CSF labs seem to support meningitis. Increased CSF pressure, turbidity and highly elevated WBC's are consistent with this theory. I would expect the glucose to be somewhat lower with meningitis though.

As for the cold, numb hand, that may be due to an concurrent spinal injury. Remember, discs don't show up on X ray.

I think there is a strong possibility of a combination of meningitis & other injury.

Thanks for putting my brain to work during lunch :)

  • Guides
Starting out with the v.s., I would tend to suspect sepsis. Elevated T, HR and RR all support this theory.

With increased ICP due to a head injury, you would expect to see depressed RR and HR, along with a widening pulse pressure (although this scenario doesn't include a B/P.)

The CSF labs seem to support meningitis. Increased CSF pressure, turbidity and highly elevated WBC's are consistent with this theory. I would expect the glucose to be somewhat lower with meningitis though.

As for the cold, numb hand, that may be due to an concurrent spinal injury. Remember, discs don't show up on X ray.

I think there is a strong possibility of a combination of meningitis & other injury.

Thanks for putting my brain to work during lunch :)

I agree . . . it doesn't have to be one or the other. He was exhibiting symptoms prior to getting hit .. and he did get hit.

steph

  • Author

Hm. I never really thought it could be *both*.

When I read this I was also thinking of a dual diagnosis. You seem on track with the meningitis; but, in addition, he could also have a concussion from the trauma. Only the late stages of increased ICP will exhbit the symptoms another poster decribed. Mild ICP will not widen pulse pressure or lower HR,especially if sepsis is looming. Also, nerve impingment from a disk is feasable because, as another poster said, this wouldn't be readily apparent from standard x-rays. An MRI would be needed to assess this hypothetical patient better.

  • Author

So we're right on with the elevated vs r/t sepsis, but his loc/sz could also be r/t a concussion? I kind of like that. Covers all our bases.

I called my dad to grill him and he went all "Occam's Razor, my dear," then recited some rhyme about zebras on the veldt. :rolleyes: Well duh, she's not going to give us a zebra, FPS. :chuckle He's such a goon.

I think it takes her a while to get back with grades because she cross-references and goes to Turn It In, but I'll let you know what the deal is when we find out.

Thanks a lot, you guys are great.

  • Experts

tbi as in traumatic brain injury? the problem i would have with that is that your scenario does not say that he was hit in the head. there's a lot of information that is vague about any injury. meningitis is an infection of the membranes of the spinal cord and/or brain that often migrates from another infected area of the body. the big tip off is the stiff neck (nuchal rigidity) which is classic for meningitis.

i would think that if he had been hit in the neck (again, the scenario doesn't say) he would be complaining of pain there. and why is his headache worse? this is what differential diagnosis in primary care, 4th edition, by r. douglas collins on page 332 has to say about nuchal rigidity (this is a physician reference):

"finding nuchal rigidity on examination has almost invariably prompted the diagnosis of meningitis and lumbar puncture, but the acute clinician will want to consider other possibilities to avoid a potentially hazard procedure.
anatomy
is the key. visualize the structures of the neck and the many causes come quickly to mind. [a drawing labels the following: subarachnoid hemorrhage, meningitis, parkinsonism, brain abscess, rheumatoid spondylitis, tuberculosis of the spine, epidemic myalgia, myositis, fracture of cervical spine, retropharyngeal abscess, cervical spondylosis]

approach to the diagnosis

the workup of nuchal rigidity requires a good history. but if one is unobtainable, no spinal tap should be performed until the cervical spine is x-rayed and the eye-grounds are examined. even with a good history, a spinal tap should be withheld if there is papilledema: a neurosurgeon should be consulted immediately under these circumstances. in a patient with fever, nuchal rigidity, no papilledema, and no focal neurological signs (particularly a dilated pupil), a spinal tap can be performed for diagnosis and immediate therapy. it is preferable, however, to have ct scan results in hand first. meningitis or subarachnoid hemorrhage is frequently found in these circumstances. ct scans and x-rays of the cervical spine and skull will still be indicated in cases where the diagnosis remains obscure."

according to dr. collins, he would have not done the spinal tap on this lad had the skull and cervical x-rays not been done and showed negative for fractures. so, the only thing that remains to exclude would be a brain hemorrhage which would be demonstrated on a ct scan which was not ordered or done. however, the history doesn't indicate if this lad was hit in the head either.

you can find links to information about meningitis on this sticky thread in the nursing student assistance forum. i recommend linking into the merck manual:

Thanks for the post! I am enjoying reading this, even though I am not yet in nursing school. :)

I wonder if there is a pathophys case of the day/week thread on allnurses? It sure would be fun to read -- and informative!

  • Author

I'd be happy to post our cases after we work them up. Endocrine is next.

FYI, New York Times has a little one every week, and there are TONS of articles and books with similar things. Go look up Burton Roueche at the library and get whatever you can find. He wrote for the New Yorker back in the '40s or so and did great case studies. Atul Gawande does them now, along with Sherwin Nuland (both have published books that discuss pathphys of various conditions; Nuland's How We Die is great).

I love that I'm taking a class that essentially lets me do what some of my favorite writers do. SO. COOL.

  • Experts
thanks for the post! i am enjoying reading this, even though i am not yet in nursing school. :)

i wonder if there is a pathophys case of the day/week thread on allnurses? it sure would be fun to read -- and informative!

students will occasionally ask for help with the pathophysiology of a disease for the care plans they are working on. as i have found pathophysiology or when answering these questions, i started collecting the posts and listing them on post #49 of a sticky thread in the nursing student assistance forum. you might find reading and/or printing some of them out practical to have. i constantly am referencing the ones for inflammation, pneumonia and congestive heart failure:

students will occasionally ask for help with the pathophysiology of a disease for the care plans they are working on. as i have found pathophysiology or when answering these questions, i started collecting the posts and listing them on post #49 of a sticky thread in the nursing student assistance forum. you might find reading and/or printing some of them out practical to have. i constantly am referencing the ones for inflammation, pneumonia and congestive heart failure:

:bowingpur:bowingpur:bowingpur as always, daytonite, you rock! that link is going to be on my computer desktop!

I'd be happy to post our cases after we work them up. Endocrine is next.

FYI, New York Times has a little one every week, and there are TONS of articles and books with similar things. Go look up Burton Roueche at the library and get whatever you can find. He wrote for the New Yorker back in the '40s or so and did great case studies. Atul Gawande does them now, along with Sherwin Nuland (both have published books that discuss pathphys of various conditions; Nuland's How We Die is great).

I love that I'm taking a class that essentially lets me do what some of my favorite writers do. SO. COOL.

I read one of Burton Roueche's books this summer. It was great!

I also either read Discover Magazine's Vital Signs or listen to the Vital Signs podcasts while I'm exercising. They help me understand how to think medically.

http://discovermagazine.com/columns/vital-signs/?searchterm=vital%20signs

http://discovermagazine.com/podcasts

Thanks for your offer to post the endocrine case next. Can you let us know what your teacher says about the possible TBI/meningitis case?

  • Author

Yeppers! She expects to have final grades Sunday night, barring infernal computation device issues (hers and mine, my motherboard is on the fritz). But if all goes well and we both have functioning computers, I'll put it up asap.

I totally love Roueche. Do you remember which one you read? I think Eleven Blue Men is my favorite. For neuro stuff also, Oliver Sacks (*sigh*) is wonderful. He has a great writing style and boy does he know his stuff. Lots in the New Yorker, and a bunch of books on his own.

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