Chief Concern

“My head hurts so bad, my neck is stiff, and I keep throwing up. Why is that bell still ringing in my left ear?”

History of Present Illness

Vivian is a 24-year-old graduate student brought to the ED by her roommate, June. Headache and malaise began this morning and progressed during the day. She took acetaminophen 500 mg at 1700 without adequate relief.

Despite feeling ill, she attended The Last Wake, a Halloween attraction inside an old chapel. During a mock eulogy, she lay in an open prop coffin while a recorded bell played. She developed worsening headache, photophobia, neck pain, and vomiting. When she struggled to sit upright, nearby guests initially assumed it was part of the performance.

June helped her out of the coffin and sought emergency assistance. After the recording stopped, Vivian continued to report ringing in her left ear. Muffled hearing has not been documented at this initial assessment. No witnessed fall, head strike, loss of consciousness, or seizure.

Past Medical History

• Occasional tension headaches.
• No known immunodeficiency.
• No other chronic medical conditions reported.
• No anticoagulant use or known bleeding disorder.

Family History

• No known familial immunodeficiency reported.
• Additional history to be clarified after stabilization.

Social History

• Graduate student residing in a shared dormitory room.
• June is her roommate and reports sharing drinks with her during the preceding week.
• No alcohol or recreational drug use reported in connection with tonight’s event.

Home Medications

Acetaminophen 500 mg PO as needed for headache; one dose taken today at 1700.

Allergies

No known drug allergies.

Review of Systems

Constitutional: Fever, chills, and malaise.

Neurologic: Severe headache, photophobia, and neck stiffness. No seizure or focal weakness reported.

ENT: Left-sided tinnitus. Hearing clarity has not yet been specifically characterized.

Gastrointestinal: Nausea and repeated vomiting.

Respiratory: No cough or dyspnea.

Skin: No rash reported before arrival.

Physical Examination

General: Acutely ill and uncomfortable; shields eyes from overhead lighting.

Neurologic: GCS 15; oriented to person, place, time, and situation. Pupils equal and reactive. No focal motor deficit. Neck stiffness present.

Cardiovascular: Tachycardic with regular rhythm. BP 116/72 mmHg, MAP 87. Capillary refill approximately two seconds.

Respiratory: RR 22/min; lungs clear. SpO₂ 98% on room air.

Abdomen: Soft and nondistended without focal tenderness.

Skin: No petechiae, purpura, active bleeding, or infection over the proposed LP site.

Laboratory Findings

Blood collected at 2105. Results became available during the ED evaluation: WBC 18.6 × 10³/µL, hemoglobin 12.8 g/dL, platelets 198 × 10³/µL, sodium 134 mEq/L, potassium 3.8 mEq/L, bicarbonate 22 mEq/L, BUN 14 mg/dL, creatinine 0.8 mg/dL, glucose 112 mg/dL, lactate 2.4 mmol/L, INR 1.0, and aPTT 29 seconds. Pregnancy test negative.

Glucose was obtained during an acute ED presentation; fasting status is unknown. Blood cultures are pending.

Diagnostics

Lumbar puncture completed at 2108 after clinical assessment found no focal neurologic deficit, abnormal pupils, seizure, hemodynamic instability, known bleeding disorder, anticoagulant use, or local puncture-site infection. Laboratory results were not documented as available before the procedure.

CSF opening pressure 28 cm H₂O. CSF is cloudy with WBC 1,850 cells/µL, 92% neutrophils, glucose 24 mg/dL, and protein 190 mg/dL. CSF/serum glucose ratio is 0.21. Gram stain, PCR, and culture are pending. No initial indication for CT before LP was identified.

Assessment

• Suspected acute bacterial meningitis; organism pending.
• Fever, severe headache, and vomiting.
• Elevated lactate requiring repeat measurement and close perfusion assessment.
• Left-sided tinnitus requiring follow-up.

Plan

• Maintain Droplet and Standard Precautions.
• Give dexamethasone before the first antibiotic dose; reassess continuation when the organism is identified.
• Start ceftriaxone and empiric vancomycin promptly.
• Give ordered fluid bolus and reassess perfusion and respiratory status.
• Treat nausea and pain; include the home acetaminophen dose in the rolling 24-hour total.
• Continuous ECG and pulse oximetry; vital signs and neurologic checks every 15 minutes.
• Repeat lactate within two hours of the initial specimen. Measure intake and urine output.
• Admit; escalate immediately for hypotension, new rash, altered mental status, or seizure.

Provider Information

Dr. Zoe Langston, MD
Emergency Medicine

Chief Concern

Worsening mental status, hypotension, and new nonblanching skin lesions during treatment for bacterial meningitis.

Interval History

At 2210, Vivian became drowsy and disoriented to time. BP decreased to 86/50 mmHg. New petechiae progressed to irregular purpuric lesions over the lower extremities and lower trunk. Lesions remained visible and nonblanching after theatrical makeup was removed from an adjacent area.

Additional normal saline 1,500 mL was administered from 2210–2250 with repeated assessment. Total crystalloid, including the initial bolus, is 2,000 mL, approximately 31 mL/kg. Hypotension persisted. Norepinephrine began at 2255 through a dedicated proximal upper-extremity peripheral IV.

BP improved to 100/60 mmHg, MAP 73, at 2302. Head CT was obtained at 2308 for new altered mental status, with continuous monitoring and uninterrupted vasopressor infusion. No acute hemorrhage, mass effect, or hydrocephalus was identified.

CSF PCR identified Neisseria meningitidis at 2300. Dexamethasone and vancomycin were discontinued. The vancomycin loading infusion was stopped before completion. Ceftriaxone continues.

At 2330, arterial BP is 88/52 mmHg, MAP 64, on norepinephrine 0.08 mcg/kg/min. Following assessment of the arterial waveform, transducer, infusion pump, and IV site, norepinephrine increased to 0.10 mcg/kg/min at 2332 within the written order. MAP improved to 69 at 2335.

Past Medical History

• Occasional tension headaches.
• No known immunodeficiency.
• No other chronic medical conditions reported.

Family History

• No known familial immunodeficiency reported.
• Further history limited by current illness.

Social History

• Graduate student living in a shared dormitory room.
• June is her roommate and therefore a household-type close contact. Shared drinks provide additional exposure history.

Allergies

No known drug allergies.

Review of Systems

Constitutional: Fever and marked weakness.

Neurologic: Persistent headache and photophobia with new confusion.

ENT: Left-sided tinnitus reported earlier. Additional hearing history cannot be obtained reliably now.

Gastrointestinal: Earlier vomiting; no further emesis observed during this assessment.

Skin: New petechiae and purpura.

Genitourinary: Reduced measured urine output.

Remaining review limited by altered mental status.

Physical Examination

General: Acutely ill, drowsy, and intermittently restless.

Neurologic: GCS 14: E4, V4, M6. Follows commands; disoriented to time. Pupils equal and reactive. No new focal motor deficit. Neck stiffness persists.

Cardiovascular: Tachycardic, cool distal extremities, capillary refill approximately four seconds. Arterial BP 88/52 mmHg, MAP 64, at 2330.

Respiratory: RR 28/min; lungs clear. SpO₂ 97% on room air.

Abdomen: Soft and nondistended.

Skin: Nonblanching petechiae and purpuric lesions over lower extremities and lower trunk. No active mucosal bleeding.

Lines and Devices: Foley and left radial arterial line present. Peripheral vasopressor site without swelling, blanching, leakage, or localized coolness.

Laboratory Findings

At 2300: WBC 24.8 × 10³/µL, hemoglobin 11.4 g/dL, platelets 72 × 10³/µL, sodium 132 mEq/L, bicarbonate 18 mEq/L, BUN 24 mg/dL, creatinine 1.3 mg/dL, glucose 156 mg/dL, lactate 5.1 mmol/L, INR 1.8, aPTT 46 seconds, fibrinogen 130 mg/dL, D-dimer 6,200 ng/mL FEU. Fasting status is unknown.

CSF PCR detects N. meningitidis. Gram stain shows gram-negative diplococci. Blood and CSF cultures remain pending.

Diagnostics

CT at 2308 showed no acute intracranial hemorrhage, mass effect, or hydrocephalus. Imaging followed documented hemodynamic improvement and did not delay initial antibiotics.

Assessment

• Meningococcal meningitis with septic shock.
• Consumptive coagulopathy concerning for disseminated intravascular coagulation.
• Acute kidney injury with reduced urine output.
• Acute altered mental status without focal deficit.
• Previously reported left-sided tinnitus.

Plan

• Continue ceftriaxone 2 g IV every 12 hours; next dose 10/26 at 0915. Planned seven-day course: 14 doses, final planned dose 11/01 at 0915, subject to infectious disease review.
• Dexamethasone and vancomycin discontinued.
• Titrate norepinephrine within order to MAP ≥65 mmHg. Reassess pressure every 2–5 minutes during titration.
• Continuous ECG, pulse oximetry, and arterial pressure monitoring; neurologic checks every 15 minutes.
• Strict hourly urine output; goal approximately ≥32 mL/hr at 64 kg.
• Repeat CBC, metabolic panel, lactate, PT/INR, aPTT, and fibrinogen at 0300, then every four hours.
• Hourly skin and bleeding assessment. Avoid unnecessary punctures and IM injections. Hold pharmacologic VTE prophylaxis.
• Maintain Droplet and Standard Precautions until at least 24 hours of effective therapy and provider review.
• Coordinate June’s chemoprophylaxis promptly as a household-type close contact, regardless of vaccination status. Do not delay pending contact screening cultures. Her prescription belongs in her own record.

Provider Information

Dr. Nadia Wells, MD
Critical Care Medicine

Chief Concern

“My headache is better, but that bell is still ringing in my left ear. Everyone sounds muffled on that side.”

Interval History

Recovering from meningococcal meningitis with bacteremia, septic shock, acute kidney injury, and consumptive coagulopathy. Norepinephrine was discontinued 10/26 at 1200. Blood pressure has remained stable without vasopressor support.

Lactate decreased to 1.4 mmol/L on 10/26 at 1600. Foley was removed at 1700 and arterial line at 1730. She continues to void spontaneously. Droplet Precautions were discontinued at 2200 after more than 24 hours of effective treatment and provider/infection-prevention review.

Transferred to Room 318 at 0730 today. Headache is 2/10. No recurrent vomiting, seizure, or confusion. Existing skin lesions have not progressed.

Left-sided tinnitus began before vancomycin and was documented at the initial ED assessment. Muffled hearing is now reported; its onset has not yet been established and requires prompt clarification. The record does not establish that muffled hearing was present before vancomycin.

Prompt inpatient hearing assessment is requested. Given unilateral hearing change during this acute illness and uncertain onset, request urgent ENT review now to assess possible sudden hearing loss. Do not defer specialist review until an audiogram is abnormal or until routine outpatient follow-up.

Past Medical History

• Occasional tension headaches.
• No known immunodeficiency.
• No known hearing impairment before this illness.
• No other chronic medical conditions reported.

Family History

• No known familial immunodeficiency reported.
• No known family history of early hearing loss.

Social History

• Graduate student in a shared dormitory room.
• June is an indicated household-type close contact. Infection prevention confirms chemoprophylaxis coordination was completed promptly; prescription and administration are documented in June’s own record.
• Mother Elena Crowe can assist with recovery planning.

Allergies

No known drug allergies.

Review of Systems

Constitutional: Fatigue; no current chills.

Neurologic: Mild residual headache; no new confusion, seizure, focal weakness, or worsening photophobia.

ENT: Persistent left tinnitus and newly reported muffled hearing. Hearing-change onset requires clarification. No ear pain or drainage.

Cardiovascular: No chest pain or palpitations.

Respiratory: No dyspnea or cough.

Gastrointestinal: Tolerating intake; no vomiting.

Genitourinary: Voiding without dysuria.

Skin: No new lesions or active bleeding.

Physical Examination

General: Awake, conversant, and fatigued.

Neurologic: GCS 15, oriented ×4. Pupils equal and reactive. Symmetric strength; no new focal deficit. Mild residual neck discomfort.

ENT: No obstructing cerumen, visible middle-ear effusion, or acute tympanic membrane inflammation. Patient reports reduced speech clarity on the left. Formal hearing thresholds and type of impairment have not been established.

Cardiovascular: Regular rhythm; BP 114/70 mmHg, MAP 85. Extremities warm; capillary refill approximately two seconds.

Respiratory: RR 16/min; lungs clear; SpO₂ 99% on room air.

Abdomen: Soft and nontender.

Skin: Existing petechiae and purpura stable and beginning to fade. No new lesions, active bleeding, or skin breakdown.

Lines and Devices: Peripheral IV present. Previous arterial site dry. No Foley catheter.

Laboratory Findings

At 0800: WBC 12.9 × 10³/µL, hemoglobin 11.2 g/dL, platelets 118 × 10³/µL, sodium 137 mEq/L, potassium 3.9 mEq/L, bicarbonate 24 mEq/L, BUN 17 mg/dL, creatinine 0.9 mg/dL, glucose 96 mg/dL, INR 1.2, aPTT 32 seconds, fibrinogen 260 mg/dL.

Latest lactate 1.4 mmol/L was collected 10/26 at 1600, not this morning. Blood and CSF cultures identify ceftriaxone-susceptible N. meningitidis.

Diagnostics

Prior CT showed no acute intracranial abnormality. No repeat imaging currently ordered. Prompt inpatient audiology and urgent ENT review requested for unilateral hearing change with uncertain onset.

Assessment

• Meningococcal meningitis and bacteremia, improving.
• Septic shock resolved; off vasopressors.
• Acute kidney injury improving.
• Improving consumptive coagulopathy with residual thrombocytopenia and anemia; no active bleeding.
• Persistent left tinnitus with newly reported unilateral muffled hearing; possible acute hearing loss requiring prompt assessment.

Plan

• Continue ceftriaxone 2 g IV every 12 hours. Three doses administered through 10/26 at 2115; fourth dose due today at 0915. Planned dose 14 remains 11/01 at 0915.
• Vital signs and neurologic checks every four hours.
• Measure each void and shift intake/output. Report sustained urine output below approximately 32 mL/hr.
• Repeat CBC and metabolic panel tomorrow morning; repeat coagulation studies for bleeding or deterioration.
• Enoxaparin 40 mg subcutaneously daily; hold for active bleeding or platelets <100 × 10³/µL and notify provider.
• Acetaminophen 650 mg PO every six hours PRN for 72 hours; maximum 3,000 mg from all sources in any rolling 24 hours.
• Clarify hearing-change onset immediately, including last known baseline hearing, sudden versus gradual change, and associated vertigo or neurologic symptoms.
• Request urgent inpatient ENT review now because sudden hearing loss cannot be excluded. If unexplained hearing loss developed over three days or less within the past 30 days, specialist assessment should occur within 24 hours. Do not wait for routine audiology follow-up.
• Obtain prompt audiology coordinated with ENT. Routine post-meningitis assessment within four weeks of being well enough remains a follow-up standard, not a reason to delay acute evaluation.
• Regular diet and assisted ambulation as tolerated. Continue fall precautions and Standard Precautions.
• Discharge planning includes antibiotic completion, hearing-care plan, recovery support, return precautions, and medical review four to six weeks after discharge. No discharge order today.

Provider Information

Dr. Priya Desai, MD
Internal Medicine