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Strongly suspected bacterial meningitis with a new focal neurological deficit — MRCEM SBA MCQ

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HardResuscitation and critical illnessStrongly suspected bacterial meningitis with a new focal neurological deficitMRCEM SBA

A 36-year-old man presents to the emergency department with eight hours of fever, severe headache, neck stiffness and worsening confusion. His GCS is 13/15, and he has new left arm weakness. His pupils are equal and reactive, blood pressure is 118/72 mmHg, and he is maintaining his airway. There is no rash. Intravenous access is established, blood cultures can be taken immediately, and CT will not be available for 40 minutes. He has no known drug allergies and has received no treatment. What is the most appropriate management sequence?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Take blood cultures, give intravenous dexamethasone and ceftriaxone, arrange CT, and perform lumbar puncture when the focal deficit has resolved and it is safe.

Fever, headache, neck stiffness and altered cognition make bacterial meningitis strongly suspected. Ordinarily, lumbar puncture precedes antibiotics when it is safe and does not cause a clinically significant delay. The new focal weakness changes that sequence: NICE recommends imaging and says not to perform lumbar puncture until the relevant clinical factor has resolved. Take blood samples and start antibiotics before imaging; the 40-minute wait for CT must not delay treatment. Give intravenous dexamethasone with or before the first antibiotic dose if possible, but do not delay ceftriaxone to administer it. Arrange CT, continue inpatient assessment and treatment, and perform lumbar puncture as soon as it becomes safe. ([nice.org.uk](https://www.nice.org.uk/guidance/ng240/chapter/Recommendations)) A incorrectly applies the usual pre-antibiotic lumbar-puncture sequence despite a focal sign. B correctly prioritises ceftriaxone and imaging but omits indicated dexamethasone. D treats prior antibiotic administration as a reason to postpone lumbar puncture until treatment is complete; NICE instead recommends puncture as soon as it is safe. E mistakes a normal scan for resolution of the clinical contraindication: persistent new focal weakness still precludes lumbar puncture. ([nice.org.uk](https://www.nice.org.uk/guidance/ng240/chapter/Recommendations))

Reference: NICE NG240: Recommendations — neuroimaging and lumbar puncture (March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/Recommendations NICE NG240: Recommendations — antibiotics and corticosteroids (March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/recommendations