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Original Question
CASE SENARIO: Mr. Xu is a 43-year-old male presenting to ED at 1600hrs. Referred by GP for likely meningitis with 3-day history of fevers and 2-day history of headaches and neck stiffness and vomiting. Following onset of vomiting, also reporting onset of abdominal pain in epigastric region and dysuria. • Brought in from waiting room after 6 hours of presentation due to busy workload • Appears unwell • Poor historian due to headache and language barrier- NESB, wife translating • Past Medical History: Nil significant Fully vaccinated against COVID ASSESMENT: Airway. – Patent Breathing. – Spontaneous, RR-19/mt, SPO2-98% RA, air-entry equal Circulation- Appears flushed in face and neck, BP-86/62 mmHg, HR- 132/mt, dry mucous membranes Disability – GCS-14 E4V4M6, not oriented to time, place or person, PEARL- 3mm- significantly photophobic on examination Exposure – Needed support to walk from waiting room to bed space. Unable to flex neck and lift head. Has cupping marks over the back, blanching lesions in cup-shaped pattern. No other visible rash identified Temperature 39.8 deg Celsius. Abdomen soft and tender +++ RUQ and epigastrium even on light palpation, bowel sounds present. Kernig’s sign negative. Fluids – Unable to tolerate oral fluids, NBM for now Glucose – BGL-9.8 mmol/ Investigations: • ABG: pH- 7.48, HCO3- 29, BE-5.2, Lactate- 4.8 • Urine analysis: Positive for nitrites and leukocytes, urine appears very concentrated • Bloods- WCC- 12.6, CRP- 176 • Urgent CT abdomen- Liver abscess, complicating hepatic vein thrombosis, no features of hepatic cirrhosis • Lumbar puncture done- CSF analysis- opalescent fluid, 28,800/cmm with 88% neutrophils, 8% lymphocytes; glucose of 6 mg/dL and protein of 508 mg/dL. CSF Gram stain revealed no organisms. • Additional information: CSF cultures – preliminary results grew Klebsiella pneumoniae, hypervirulent strain via rapid testing (report received after 12 hours of LP). • Diagnosis: Disseminated sepsis secondary to ?meningitis ? Urinary tract infection A MET call was activated at 2230hrs QUESTION: Q4. Discuss TWO diagnostic results and relate it to the underlying pathophysiology.
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