27. Fever and irritability: outpatient visit
Doctor: Hello, Mrs. Murphy. How is your daughter Helen doing since last week?
Mother: Hello Dr. Anderson. Actually we’ve come back because she seems to be getting worse.
Doctor: OK. If I remember well, Helen is three years old and she started with a fever six days ago, with cold symptoms and acute otitis media, is this correct?
Mother: Yes, she has been taking the antibiotic as you prescribed, but she still has high fever, she has been eating less and yesterday she slept more than usual. Since she woke up this morning, she has been very whiny and she’s vomited the whole breakfast.
Doctor: Let’s take a quick look at Helen.
Weight: 15 kg. Axillary temperature: 38ºC. BP: 125/63 mmHg. HR: 168 bpm. Ill appearing, well-nourished and hydrated. Capillary refill time: 2 seconds. Normal symmetrical peripheral pulses. No rashes or petechiae. No signs of respiratory distress. Neurological: significant irritability, difficult to soothe in her mother’s arms, reacts to stimuli. PERRL. Closed anterior fontanelle. Nuchal rigidity. Positive Kernig and Brudzinski signs. No focal neurologic findings. Cardiac auscultation: rhythmic tachycardia, no heart murmurs. Pulmonary auscultation: general good bilateral ventilation, transmitted upper airway sounds. HEENT: hyperemic oropharynx. Hyperemic right tympanic membrane, normal left tympanic membrane. Normal abdomen, no masses or organomegalies.
Doctor: Mrs. Murphy, I’m afraid Helen has signs of meningitis. This could be a complication from her acute otitis media and according to the signs and symptoms it is likely that it is bacterial. We are going to send her to the hospital as soon as possible, but now we have to administer the first dose of antibiotics.
Mother: Is it serious? Why does she need to go to the hospital?
Doctor: Meningitis is an infection of the lining that covers the brain and spinal cord. She needs to be taken to the hospital because she will need several blood tests, a lumbar puncture and possibly a CT scan of the brain. It must be treated as quickly as possible to avoid complications.
Mother: What kind of complications?
Doctor: The most frequent complications are hearing loss or learning problems, although there is a wide range. Fortunately, Helen has no underlying conditions, her level of consciousness is not severely affected and we are going to start her on antibiotics right away, so there is a chance that she won’t have any complications at all. However, we’ll have to wait and see.
Mother: How long will she have to stay in the hospital? Is it contagious?
Doctor: The hospital stay depends on the clinical course. She will probably need IV antibiotics for at least ten days. As to whether it is contagious, it depends on the type of bacteria, they will give you more information at the hospital. Now we have to administer intramuscular ceftriaxone and arrange the transfer to the hospital. Please wait here, I will be back in a moment.
Mother: Thank you Dr. Anderson.
Difficult to soothe: difícil de calmar.
PERRL (pupils equal, round and reactive to light): pupilas isocóricas y normorreactivas.
Nucal rigidity: rigidez nucal.
Focal neurologic findings: signos de focalidad neurológica.
Transmitted upper airway sounds: ruidos transmitidos de vía aérea superior.
Lining that covers the brain: revestimiento que cubre el cerebro.
Spinal cord: médula espinal.
Lumbar puncture: punción lumbar.
CT scan: tomografía computarizada (TC).
Hearing loss: pérdida auditiva.
Learning problems: problemas de aprendizaje.
Underlying conditions: condiciones médicas subyacentes.
Level of consciousness nivel de consciencia.
Hospital stay: estancia hospitalaria.
Clinical course: evolución clínica.
Transfer to the hospital: traslado al hospital.