Tuesday, November 20, 2012

A Father's Love



I was working in an infectious disease medicine group at a major academic hospital.  The holidays were fast coming upon us, so the hospital was all decked out with merry decorations of green and red.  As I came into work that day I was still feeling stuffed from all that I had eaten the day before on Thanksgiving.

Usually such a holiday weekend, though being a long with needing to work 3 days, would be quiet.  We didn’t get a lot of admissions, and most patients were asking to be discharged, instead being followed as out-patients. 

It was into this picture, that I received a page from my supervising physician to go down to the emergency room and see a 35 year old male patient.  From the sounds of it, he was ill and needed to be admitted to the hospital.  I scurried down to the emergency room and began working the new patient up.

Upon arriving in the emergency room, I walked over to the curtain and pulled it aside.  Laying in the bed was a middle-aged man, with his eyes closed trying not to move.

“Hi, I’m Sharon, I’m a physician assistant and was asked to come down and see you.  Am I to assume you’re Tom Arnold?”
“Um, yeah, I’m Tom.”
“I’ve been told you have a really bad headache and a fever.  What can you tell me about your symptoms?”
“Um, can you pull that curtain behind you, so that it’s closed?  The light is really bothering my eyes.”
“Sure,” and with that I pulled it closed again, trying to block as much light as I could from the emergency room overhead lights.
“Thanks.”
“Okay, can you tell me when you started getting sick?”
“Yesterday, I woke up not feeling very well, but with it being Thanksgiving and all I had to get up and help my wife keep an eye on our three kids.  So with my keeping an eye on the kids, my wife stayed in the kitchen fixing our holiday meal.  As yesterday wore on, I started feeling worse, my head really started hurting and I started feeling somewhat nauseated.  By dinner,  I just didn’t want to eat, I was afraid that I would just throw it back up.  So I sat at the dinner table and just sipped some cold water.  After dinner, I couldn’t stay awake any longer, I felt so bad I went back to bed.”
“So, when did you fevers start?”
“Probably some time in the afternoon, yesterday.”
“Do you have any other symptoms?”
“Yeah, now that you ask, my neck really hurts.  I also have a runny nose, it’s like a water faucet, just clear drainage.”
“Any rash, or other symptoms?”
“No.”
“Anyone in your family ill, lately?”
“Yeah, my three year old son just got over a really bad cold, he’d had it for over a week, before he finally cleared the cold virus.  I spent quite a few nights rocking him to sleep because he was having a hard time sleeping due to his cough and nasal congestion.”
“Okay, well I have a few more questions for you.  Do you have any chronic medical conditions, such as hypertension, or diabetes?”
“No.”
“So, you’re not on any daily medications?”
“No, I don’t take anything.”
I asked him about his family history, social history and found out that it was all non-contributory.  He worked as an electrical engineer for the local gas company.
“We’re going to have to do a lumbar puncture on you to see whether you have meningitis.  I’ll also have the nurse come in and draw blood cultures, a blood count and blood chemistry panel on you.  I’ll be back with the infectious disease fellow who will do the lumbar puncture.    I see that they have already started an IV on you and begun to run some fluids into you, which should help to bring down your fever of 102 F.  I’ll also have the nurse give you some Tylenol for your headache/fevers.   We’ll get the testing done as soon as possible.   Any questions?”
“No, I don’t think so.  What do you think I have?”
“It sounds as though you have meningitis, it could be viral meningitis, seeing that your son has had a  cold.”
“Oh, that sounds bad.”

“No, not necessarily.  Let us finish our testing first.  Let me go get the nurse assigned to you to draw your blood work and I’ll come back and do my exam, listening to your lungs, heart, etc.  After that I’ll page the the infectious disease fellow to come down and do your lumbar puncture.”
“Um, okay, as long as I can get that Tylenol pretty quickly, my head is just throbbing.”
“I’ll be back shortly.”

A half-hour later, I had completed the patient’s physical exam and the nurse had gotten all of his blood work drawn.  Besides his stiff neck and runny nose I didn’t find anything else on his physical exam.  I called my infectious disease fellow and he showed up within a few minutes to do the lumbar puncture.  After drawing off several tubes of spinal fluid, the ID fellow left and I completed writing out the admission orders.  Now it was time for the lab to tell us what the cell count was and we would know shortly what kind of meninigitis we were dealing with. 

Patients who present with meningitis generally have acquired it from one of several risk factors. 
Viral meningitis:  which is typically caused by herpes, HIV, mumps, varicella (chicken pox), or enterovirus (typical common cold virus for instance).
Tuberculosis,
Fungus (in immunocompromised patients who are on chemotherapy for cancer, for instance),
Tick borne from lyme disease or rocky mountain spotted fever,
Syphilis,
Bacterial related, such as from strep bacteria, gonorrhea strains, H. flu
Neoplasm spread: usually from leukemia
Drug induced: several different drugs can induce a meningitis type picture

The usual signs and symptoms of meningitis include: light sensitivity (photosensitivity), nausea, vomiting, fatigue, malaise, neck rigidity, headache, fever, abrupt onset of symptoms as well as a possible rash.  Patients typically look ill, they don’t want to move around and they prefer a dark room.

I went back upstairs and joined my team on afternoon rounds, which had just started. Twenty minutes later the ID fellow was paged and came back to tell me that our new patient we had seen in the emergency room looked to have viral meningitis, based on his spinal tap results.  The nurses were getting him situated on 21East, a medicine floor.  That was our next floor down, so the team would be seeing him shortly.

The patient’s cell count from his lumbar puncture showed him to have a white blood cell count of 150, a normal glucose, a normal protein count.  His blood work showed that he had a blood white blood cell count that was predominately lymphocytes (which fight off virus’), a normal chem 7 (electrolytes and renal function).  With the history of his son having a recent viral infection, he did indeed have a case of viral meningitis.  So now he just needed to be kept hydrated, get plenty of Tylenol for his headaches, give him some Ativan for his nausea/vomiting and see how he was in the am.  If he, as other patients with viral meningitis have done, felt better then we could discharge him home and have him see his primary care physician in a week to make sure all of his symptoms had resolved. 

Doing a lumbar puncture (spinal tap) is the most important test to do on patients who are suspected of having meningitis.  The various tests that we can run on the spinal fluid tells us a lot.  The cell count will tell us whether we are dealing with a viral infection (the count will come back with a predominance of lymphocytes), bacterial infection (cell count will be a predominance of neutrophils), or some other etiology, such as neoplastic spread (immature cells called blasts will be present).  Gram staining will be positive if it is a bacterial infection.  In bacterial meningitis there is also usually a high protein and low glucose count.  (bacteria produce protein, use glucose). 

Blood counts for the patient’s white blood cell count, differential of those white blood cells, as well as the patient’s electrolytes and renal function (kidneys) is important to know.  Electrolytes and renal function will tell you how hydrated the patient is (i.e. how much nausea/vomiting they’ve had). 

Patients who have a bacterial origin for their meningitis need to be started on IV antibiotics immediately after their spinal tap.  The type of IV antibiotics is based upon the patient’s age, immune status, and possibly risk factors.  They also need to receive IV hydration to help keep their fever down as well as help prevent any pre-renal azotemia (dehydration that leads to increased renal parameters, i.e. renal insufficiency.)

The following morning before rounds I went to go check on my newly admitted patient.  He was sleeping comfortably, with his wife sitting in the chair besides him.  I quietly asked her whether he had been able to eat anything and she said he had a snack last night and keep it down.  The nurse’s notes stated that his fevers had stayed down with him being on Tylenol.  I excused myself and went out to the nurse’s station and began writing his discharge orders.  This father would do fine.  He had learned yet another lesson in parenting, how kids love passing on their bugs to anyone around them, especially their mom and dad. 

  

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