werner@aecom.UUCP (Craig Werner) (02/02/86)
<<<>>> > A young recruit, previously healthy, comes into clinic after being > ordered to see you by his drill Sergeant. > As he sits head upright and straight as an arrow, he tells you his > symptoms, which are: "I feel real tired, Sir. I've got the worst headache > I've ever had in my life, and my eyes hurt in the sun." He also has a > temperature of 102. > After discussing the case with your attending physician (and Senior > officer), you discover that you have no choice but to immediately admit this > person to the hospital for diagnostic tests. > > 1. What is the suspected diagnosis and why has it been written into > MilRegs (Military Regulations)? > 2. What obvious symptom isn't the patient telling you about (Read > carefully!) > 3. What's the test to do in the hospital? The hidden symptom is a stiff neck, which could fairly easily be mistaken for proper erect military posture, even in a civilian. So we have: Stiff Neck (also called Nuccal Rigidity), Headache, Photophobia and Fever. These are the classic signs of Meningitis. Meningitis, an infection of the lining of the brain, can be caused by bacteria (the exact bacteria varies with patient age), fungi, or viral. Bacterial meningitis, which in and of itself, is the worst form of the disease, is also the most frequent form of epidemic meningitis, particularly among military trainees, who live in such close quarters. Hence by MilRegs, any soldier with a fever of 102 or greater and a headache must be admitted to the hospital with presumed Meningitis until proven otherwise. [See end of the article.] The test to do in the hospital is a Spinal tap (also called a Lumbar Puncture). Examination of the Cerebrospinal fluid will yield a diagnosis. Normal CSF is clear, has very little cells, has ample Glucose, and very little protein. Bacterial meningitis will cause a Turbid CSF, caused by Polymorpho- nuclear White Blood Cells. Bacteria may also be seen, and probably can be cultured. Also, Glucose will be low, and protein high. Sometimes this is the only clue. Viral will usually have less cells, they will be mononuclear, glucose may be normal, and protein only slightly elevated. Ditto Fungal (although in fungal - you also need suspicion, since people who get fungal are always ill to begin with.) [Got that: they'll be a short quiz later on] I should also note two things. 'Classic' in general medical usage means 'Seldom, if ever.' Also, the chances of someone with a fever, headache (w/ or w/o Photophobia - after all many migraines headaches come with photophobia) , and stiff neck actually having Meningitis is something along the lines of 3%. Of course, doing 97 needless spinal taps is probably worth the 3 that come up positive, since Bacterial meningitis is very contagious, is very damaging, and is very treatable. (In adults, Neisseria meningititis is almost always Penicillin sensitive, unlike its cousin N. Gonorrheae.) Hence the odds are that this person has the Flu, and the stiff neck is due to strain (the most common cause of stiff neck) or the myalgia associated with fever. On the other hand, one must rule out Meningitis, or the lawyers will descend without mercy (not to mention the potential damage to the patient). -- Craig Werner !philabs!aecom!werner "Comedy, like Medicine, was never meant to be practiced by the general public."