View source for WBR1095

 {{WBRQuestion
|QuestionAuthor=Chetan Lokhande
|ExamType=USMLE Step 3
|SubCategory=Head and Neck, Neurology, Infectious Disease
|SubCategory=Head and Neck, Neurology, Infectious Disease
|SubCategory=Head and Neck, Neurology, Infectious Disease
|SubCategory=Head and Neck, Neurology, Infectious Disease
|SubCategory=Head and Neck, Neurology, Infectious Disease
|SubCategory=Head and Neck, Neurology, Infectious Disease
|SubCategory=Head and Neck, Neurology, Infectious Disease
|SubCategory=Head and Neck, Neurology, Infectious Disease
|Prompt=An 11-month-old previously healthy African American female from Haiti comes to Emergency room (ER) with generalized tonic clonic seizures with 1-day history of lethargy, fever and altered mental status. Enroute to hospital, emergency medical team intubated her and gave a dose of lorazepam, with no remission. In the ER 1 more dose of lorazepam was given and patient was transferred to ICU for further management, where vitals were within normal limits. Overnight EEG showed a pattern of status epileptics. The patient was medically paralyzed and put on a ventilator. Complete blood count, Chem 10 and CT scan all are within normal limits. She was given a dose of quinine for malaria, but stopped due to negative thick and thin smear. What is the next step in the management of this patient?
|Explanation=A history of fever and seizures in a 11 month old child is  highly suggestive of an infection . Since the patient is from Haiti where malaria and other parasitic infection are endemic an empirical therapy of anti malarial should be started right away . Since the thick and thin smears are negative malaria is ruled out and other infectons should be thought about. The next step in the management is do a lumbar puncture and rule out other infection like meningitis from encephalitis.

'''Educational objective''':
Rule out encephalitis and meningitis before starting empirical therapy in a case of unknown sezirues with fever. Lumbar puncture is always the next best step in the management.
|AnswerA=Start antiepileptic medications.
|AnswerAExp='''Incorrect''': Antiepileptic medications should not not be started  before obtaining a lumbar puncture.
|AnswerB=Start broad-spectrum antibiotics.
|AnswerBExp='''Incorrect''': First a lumbar puncture should be performed before starting antibiotics.
|AnswerC=Start steroids.
|AnswerCExp='''Incorrect''': Steroids have not been proved to be the effective in meningitis except in Tb meningitis. Also a lumbar puncture is the best initial step in this case to rule out meningitis from encephalitis.
|AnswerD=Start with antiviral and antimalarial treatment together.
|AnswerDExp='''Incorrect''': Before starting any antibiotic therapy or empirical treatment lumbar puncture must be performed to rule out meningitis from encephalitis.
|AnswerE=Order a Lumbar Puncture.
|AnswerEExp='''Correct''': The best next step in the management of fever and seizures is doing a lumbar puncture to rule out meningitis from encephalitis.
|RightAnswer=E
|WBRKeyword=Lumbar puncture, Meningitis, Encephalitis.
|Approved=Yes
}}