The Teenager With 'Just a Headache'
A 15-year-old presents with 2 days of worsening headache, now 'the worst of my life,' with vomiting and photophobia. Temp 37.9 C, HR 92, BP 118/70, RR 18, SpO2 99%. She is alert but uncomfortable, with neck stiffness on passive flexion and no rash. She is on an oral contraceptive and reports a recent 'bad cold.' Pupils equal and reactive; no focal deficit. She is tearful and says, 'Please don't do a spinal tap, I'm scared.' The ED is busy and the CT scanner has a 2-hour wait. A colleague suggests giving antibiotics and sending her home with neurology follow-up because she is 'stable and talking.'
1. Should this patient be discharged with follow-up? Justify your answer.
Read the worked answer
No - discharge is unsafe.
This presentation has meningitis red flags: worst-ever headache, vomiting, photophobia, and neck stiffness. 'Stable and talking' does not exclude early bacterial meningitis or other dangerous causes (subarachnoid hemorrhage, venous sinus thrombosis on OCPs, intracranial mass).
Key reasoning:
- Do not discharge a patient with suspected CNS infection before LP or an alternative definitive pathway, and do not let ED crowding drive a premature disposition.
- If bacterial meningitis is suspected, start empiric antibiotics (and consider dexamethasone) promptly; do not delay antibiotics for imaging or LP if there is any delay.
- The CT-before-LP decision should be based on risk factors for herniation (focal deficit, papilledema, altered mentation, seizure, immunocompromise), not on scanner availability. If none are present and the patient is low risk, LP can proceed without CT.
Judgment point: the exam tests that throughput pressure must not override a red-flag workup, and that antibiotics are time-critical.
2. The patient is frightened of the LP. How do you address her fear while completing the necessary workup?
Read the worked answer
Adolescent-centered communication:
- Validate: 'It makes sense to be scared. I want to explain exactly what will happen.'
- Explain why the LP matters and what it will and will not feel like (positioning, local anesthetic, brief pressure), and that she can have a support person and distraction.
- Offer analgesia/anxiolysis as appropriate and informed assent, respecting her developing autonomy while involving parents.
- Use shared decision-making: explain the alternative (empiric treatment and admission without LP) and its trade-offs, and document the conversation.
Clinical structure:
- If CT is indicated by herniation risk factors, obtain it; otherwise proceed to LP when safe.
- Do not let the fear delay antibiotics if meningitis is suspected - treat first, LP when feasible.
- If LP is deferred, admit for observation and treatment; never discharge.
Judgment point: the exam tests procedural fear management, assent, and not letting anxiety substitute for indicated care - while keeping antibiotics timely.