1. Step 8
1.1. Diagnostic decision
1.1.1. pneumococcal meningitis
1.1.2. mastoditis and chronic otitis media
1.2. Mechanism
1.2.1. bactrial invasion from ear causing meningitis
1.3. Presentation
1.3.1. fever, neck stifness, drowsness, headache , R eye pain, cranial nerve palsy
1.4. Supporting data
1.4.1. CT + exam + CBC and blood culture
1.5. 10 minutes
2. Step 6
2.1. Review session 1
2.2. Report new knowledge
2.2.1. anatomy of meningies
2.2.1.1. three meningies sorround the brain and the spinal cord
2.2.2. CNS infection
2.2.2.1. meningitis
2.2.2.1.1. causes
2.2.2.1.2. pathopgusiology
2.2.2.1.3. presentaiont
2.2.2.1.4. doagnosing
2.2.2.1.5. epidemiology
2.2.2.2. enkephlitis
2.2.2.2.1. causes
2.2.2.2.2. pathopgusiology
2.2.2.2.3. presentaiont
2.2.2.2.4. doagnosing
2.2.2.2.5. epidemiology
2.2.3. corneal reflex
2.2.3.1. trigeminal + facial
2.3. 30 minutes
2.3.1. The scribe does not have to write in this step!
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complain
3.1.1.1. 2 weeks, headache+ eye problem
3.1.1.1.1. also cheeck and eye were sore
3.1.1.2. week before, unsteady on his feet, worsen eye
3.1.1.2.1. walking as if he drunk
3.1.1.2.2. has fallen several times
3.1.1.3. week before the visit
3.1.1.3.1. face not moving probwerly
3.1.1.3.2. R eye not closed and moved
3.1.1.4. sore neck and high fever on the day of GP visit
3.1.1.5. headache
3.1.1.5.1. frontal , sever to make him cry
3.1.1.5.2. with vomiting on several occasions
3.1.1.6. fever
3.1.1.6.1. through out the day
3.1.1.7. recurrent discharge due to R ear infection for a year
3.1.1.7.1. treated by antibiotic
3.1.1.7.2. intermittin pain for 2 months
3.1.2. Previous medical / surgical history
3.1.2.1. no history of trauma
3.1.2.2. all vaccination
3.1.2.2.1. hepatitis B + HIB
3.1.2.3. was in GD health
3.1.2.4. occusional URT infection
3.1.2.5. normal full term pregnancy
3.1.2.6. birth weight = 3.5 KG
3.1.2.7. discharged 7 day of delivery
3.1.2.8. gd dvelopment
3.1.2.9. ruptured ear drump
3.1.3. Drug history / allergy
3.1.3.1. courses of antibiotis
3.1.3.2. no allergies
3.1.4. Family history
3.1.4.1. no serios family history
3.1.5. Social / occupational history
3.1.5.1. with his mother and brother
3.1.5.2. lives in sudair
3.1.5.3. lives in the grandmother house
3.1.5.4. 6 y old brother
3.1.5.5. seperated parents
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. vital signs
3.1.7.1.1. T 39
3.1.7.1.2. P 160
3.1.7.1.3. RR 36
3.1.7.1.4. BP 90/55
3.1.7.2. general appearance
3.1.7.2.1. drowsy, could be roused by shaking
3.1.7.2.2. sweaty
3.1.7.2.3. unable to stand
3.1.7.3. L ear drump retracted, purlunt rihnorrhea
3.1.7.4. R tympanic membrane couldnt be visiualized
3.1.7.5. swollen in the R mastoid area
3.1.7.6. eyes
3.1.7.6.1. swollen of optic disc , torous pain
3.1.7.6.2. no haemorage
3.1.7.6.3. R eye didnt passed midline
3.1.7.6.4. R corneal reflex
3.1.7.6.5. weakness of eye closure
3.1.7.6.6. L eye OK
3.1.7.6.7. accomdation equal
3.1.7.7. neck stifness
3.1.7.7.1. cried with neck flexsion
3.1.7.8. motor exam and reflexes of lower limbs are normal
3.1.7.9. lymph node
3.1.7.9.1. enlargged anterior and posterior cervicle region
3.1.8. tests results
3.1.8.1. CBC
3.1.8.1.1. bacterial infection
3.1.8.1.2. CRP high
3.1.8.1.3. biochmestry test normal
3.1.8.2. radiological
3.1.8.2.1. chest x-ray
3.1.8.2.2. CT