CASE 3

TUBERCULOUS Meningitis
Stephen A. Ujano
General Data: R.S. 20 y/o, male, from Bangui. Ilocos Norte
Chief Complaint: Headache
History of Present Illness:
4 weeks PTA, patient had on and off low grade fever, occasional cough and colds.
2 weeks PTA, still with on and off fever, consult private MD, was given Paracetamol and Chloramphenicol.
No relief noted. Noted to have bloody sputum.
1 day PTA, still with fever, headache, and noted to have 5 episodes of vomiting, hence, consult was done.
Past Medical History: Admitted for Pneumonia 2 months ago
PE:
V/S: BP-120/90 HR: 90 bpm RR: 22 cpm
Anicteric sclerae, with cervical lymphadenopathy
Clear breath sounds
No murmur, full and equal pulses
Neurologic Exam: MSE: Conscious, coherent
Cranial Nerves: left lateral rectus palsy; (+) nuchal rigidity

SALIENT FEATURES:
HISTORY
o 20 y/o, MALE
o History of:
o low grade fever and occasional cough and colds,
o on and off fever
o no relief with Paracetamol and Chloramphenicol
o bloody sputum
o Headache
o Vomiting (5x)
o Admitted 2 mos ago due to Pneumonia
PHYSICAL EXAMINATION
o Vital Signs: Tachypneic (22cpm)
o (+) cervical lymphadenopathy
o Clear breath sounds
o Neurologic exam:
o Mental Status: Conscious and coherent
o (+) left lateral rectus palsy
o (+) nuchal rigidity
ADMITTING DIAGNOSIS:
o To consider Central Nervous System Infection secondary to possible Pulmonary
Tuberculosis
Formulating the Differential Diagnosis
a. What is the chief complaint?

- Headache
b. Categorize headache as to Primary or Secondary
- Secondary due to an identifiable cause/disease; CNS infection.
c. What are the common causes Secondary Headache?
- Acute Sinusitis
- Meningitis
- Intracranial Hemorrhage
- Intracranial Abscess
- Brain Tumor
- Temporal Arteritis
- Medication-Overuse Headache (most common according to WHO)
d. Determine the headache syndrome as to Acute Recurrent, Acute Non-Recurrent,
Chronic Progressive or Chronic Non-Progressive.
- Acute Non-Recurrent. The onset was sudden and occurred just 1 day PTA.
e. What are the common causes of Acute Non-Recurrent Headache?
- Acute Sinusitis
- Meningitis
- Intracranial Hemorrhage
DIFFERENTIAL DIAGNOSIS #1
ACUTE RHINOSINUSITIS
Typical Presentation
Risk Factors:
o F>M
o Hay Fever
o Exposure to pollutants
o Nasal passage abnormality (polyps)
o Medical conditions (GERD, cystic
fibrosis)
Clinical Manifestations:
o Acute headache
o Fever
o Facial pain/pressure
o Nasal drainage & congestion
o Coughing
o Sneezing
o Redness over the cheeks,
nose or eyelids

Patient Presentation
Risk Factors:
o F>M
o Hay Fever
o Exposure to pollutants
o Nasal passage abnormality (polyps)
o Medical conditions (GERD, cystic
fibrosis)
Clinical Manifestations:
o Acute headache
o Fever
o Facial pain/pressure
o Nasal drainage & congestion
o Coughing
o Sneezing
o Redness over the cheeks,
nose or eyelids