What are the key components of a physical exam for a patient with suspected meningitis, considering their past medical history and potential for rapid deterioration?

Physical Examination for Suspected Meningitis

The physical examination for suspected meningitis must prioritize immediate assessment of airway, breathing, circulation, and Glasgow Coma Scale (GCS) documentation within the first hour, followed by systematic evaluation for signs of increased intracranial pressure, meningeal irritation, sepsis, and rash—all while recognizing that patients can deteriorate rapidly regardless of initial vital signs. 1

Immediate Priority Assessments (Within First Hour)

Airway, Breathing, and Circulation

• Assess airway patency and respiratory adequacy immediately—intubation should be strongly considered if GCS <12 1, 2
• Evaluate breathing pattern, oxygen saturation, and need for supplemental oxygen or ventilatory support 1
• Check cardiovascular stability: blood pressure, heart rate, capillary refill time (<2 seconds is target), and peripheral perfusion 1
• Examine for dusky or cold extremities indicating impaired perfusion, particularly in meningococcal sepsis where young patients maintain blood pressure until late deterioration 1

Neurological Assessment

• Document GCS score immediately for prognostic value and to monitor changes—this is mandatory 1, 2
• Perform pupillary examination as abnormal pupils (size, reactivity, symmetry) indicate increased intracranial pressure or brainstem herniation and represent an absolute contraindication to lumbar puncture 3
• Assess for focal neurological signs: asymmetric weakness, cranial nerve palsies, visual field defects, or lateralizing signs—any of these contraindicate immediate lumbar puncture 1
• Evaluate for seizure activity (continuous or uncontrolled seizures contraindicate immediate LP) 1, 2

Signs of Increased Intracranial Pressure

• Examine for papilledema via fundoscopic examination—presence mandates neuroimaging before lumbar puncture 1
• Note that inability to visualize the fundus is NOT a contraindication to LP, especially with short symptom duration 1
• Assess level of consciousness: GCS ≤12 requires neuroimaging before LP and triggers ICU consultation 1

Meningeal Irritation Signs

Classic Meningismus

• Assess for neck stiffness/nuchal rigidity—resistance to passive neck flexion 4, 5
• Test for Kernig's sign: resistance or pain with knee extension when hip is flexed 4
• Test for Brudzinski's sign: involuntary hip/knee flexion when neck is passively flexed 4
• Note that absence of these signs does not exclude meningitis, particularly in early disease or immunocompromised patients 6

Rash Assessment

Critical for Meningococcal Disease

• Systematically examine entire body for rash, including mucous membranes and conjunctivae 1
• Document presence or absence of rash and whether it is rapidly evolving—this must be recorded for all patients 1
• Characterize rash type: petechial, purpuric, maculopapular, or blanching 1
• A rapidly evolving rash indicates meningococcal sepsis requiring immediate antibiotics after blood cultures, fluid resuscitation, and ICU transfer—LP should NOT be performed at this time 1
• Check for signs of limb ischemia in meningococcal sepsis 1

Sepsis Evaluation

Signs of Severe Sepsis/Shock

• Measure capillary refill time (target <2 seconds) 1
• Assess skin temperature and color (mottling, pallor) 1
• Document urine output if available 1
• Calculate National Early Warning Score (NEWS): aggregate score ≥5-6 or single parameter score of 3 prompts urgent senior review; score ≥7 requires critical care assessment 1
• Do not be falsely reassured by low early warning scores—patients with meningitis can deteriorate rapidly despite initially reassuring vital signs 1, 2

Additional Physical Examination Components

Identify Potential Source/Complications

• Examine ears for otitis media (potential source of pneumococcal meningitis) 7
• Examine sinuses for tenderness (sinusitis as source) 7
• Auscultate lungs for pneumonia (associated with pneumococcal meningitis) 5
• Examine for signs of head trauma or neurosurgical procedures (risk for nosocomial meningitis) 5

Immunocompromise Assessment

• Look for signs suggesting immunocompromise: oral candidiasis, wasting, lymphadenopathy, Kaposi's sarcoma 5
• Document any indwelling catheters or recent procedures 5

Critical Decision Points Based on Physical Exam

Contraindications to Immediate Lumbar Puncture

Neuroimaging required before LP if ANY of the following present: 1, 3

• Focal neurological signs (including abnormal pupils)
• Papilledema
• Continuous or uncontrolled seizures
• GCS ≤12
• History of CNS disease (mass lesion, stroke, focal infection)
• New-onset seizure

Immediate ICU Consultation Required

Transfer to critical care if: 1, 2

• Rapidly evolving rash
• GCS ≤12 (or drop of >2 points)
• Cardiovascular instability despite initial resuscitation
• Evidence of limb ischemia
• Hypoxia or respiratory compromise
• Uncontrolled seizures
• Acid/base disturbance

Immediate Antibiotics After Blood Cultures

Do NOT wait for LP if: 1

• Signs of shock or severe sepsis present
• Rapidly evolving rash
• LP cannot be performed within 1 hour
• Patient requires neuroimaging before LP

Common Pitfalls to Avoid

• Never delay senior clinician review—most patients should be seen much earlier than the standard 14-hour consultant review time 1
• Never rely solely on early warning scores—meningococcal sepsis patients can maintain blood pressure until catastrophic late deterioration 1
• Never perform LP in presence of focal signs, papilledema, or altered consciousness without prior imaging—this risks cerebral herniation 1, 3
• Never delay antibiotics waiting for LP or imaging—this significantly increases mortality 8, 2, 3
• Never assume absence of neck stiffness excludes meningitis—sensitivity is imperfect, especially early in disease 6
• Document pre-admission antibiotic use—this affects diagnostic yield but should not delay treatment 1