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

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HardNeurological emergenciesSuspected bacterial meningitis with a new focal neurological deficitMRCEM SBA

A 38-year-old woman arrives in the emergency department after six hours of fever, severe headache and increasing confusion. Her temperature is 39.2°C. She has neck stiffness, a Glasgow Coma Scale score of 13 and new left arm weakness, which persists on repeat examination. Her pupils are equal and reactive, blood pressure is 118/74 mmHg and capillary glucose is 5.6 mmol/L. Her airway is maintained. She has no known drug allergies, and has received no antibiotics. Intravenous access is established and CT is available urgently. What is the most appropriate initial investigation and treatment sequence?

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

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Correct answer: E — Take blood cultures; give intravenous ceftriaxone and dexamethasone; obtain CT; defer lumbar puncture until the weakness resolves.

Fever, headache, neck stiffness and confusion make bacterial meningitis strongly suspected. The new, persistent focal weakness changes the investigation sequence: she needs neuroimaging, and lumbar puncture should not be performed while that focal feature persists. Take blood cultures promptly, then give intravenous ceftriaxone without waiting for imaging. Give intravenous dexamethasone with or before the first antibiotic dose if possible; arranging it must not delay ceftriaxone. She needs urgent inpatient specialist assessment and reassessment of when lumbar puncture becomes safe. ([nice.org.uk](https://www.nice.org.uk/guidance/ng240/chapter/recommendations)) A delays treatment for CT and lumbar puncture. B applies the usual preference for lumbar puncture before antibiotics despite a focal neurological feature that makes it unsafe now. C gets treatment and imaging in the right order, but a normal CT alone does not resolve the persisting weakness or authorise lumbar puncture. D appropriately prioritises ceftriaxone and defers lumbar puncture, but unnecessarily postpones dexamethasone when it is available for administration with the first antibiotic dose. ([nice.org.uk](https://www.nice.org.uk/guidance/ng240/chapter/Recommendations))

Reference: NICE NG240: Recommendations — recognising and investigating suspected bacterial meningitis (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/Recommendations NICE NG240: Neuroimaging and lumbar puncture, recommendations 1.4.6–1.4.10 (19 March 2024) — https://www.nice.org.uk/guidance/ng240/resources/meningitis-bacterial-and-meningococcal-disease-recognition-diagnosis-and-management-pdf-66143949881029 NICE NG240: Antibiotics and corticosteroids for bacterial meningitis, recommendations 1.6 and 1.8 (19 March 2024) — https://www.nice.org.uk/guidance/ng240/chapter/Recommendations