I wanted to check in with you to give you an update on Ella Cruz. Based on what we’ve seen so far in her history and the exam, it’s possible she could have a CNS infection like meningitis, although it’s too early to eliminate other diagnoses until we have reviewed the test results. I went ahead and gave her some acetaminophen for the fever, started an IV with fluids because she was somewhat dehydrated, and also started her on IV Ceftriaxone and Acyclovir to prevent the possible progression of bacterial or viral meningitis. I chose to go this route because both diagnoses are serious and progress rapidly and because the risks of giving these antibiotics are minimal.

I checked on Ella early this morning and she is stable, but shows no improvement in her symptoms. Her fever has gone down to 99, but this is likely due to the acetaminophen.

Your Job

Please carefully review the updates to her chart and update your thinking on this case. Specifically, review your differential diagnosis and see if the new information we have received necessitates a change in your prioritization of diagnoses. Are there any that you can rule out? Are there any that seem less likely given what we know now? Are there any diagnoses that should be given a higher priority based on these results?

Once you have reordered your differential, please recommend any additional tests you would like to be performed. Keep in mind, we don't want to put the patient through any unnecessary tests or treatment, but because of the seriousness of the situation we need to thoroughly evaluate all possible diagnoses.

Finally, based on the revised differential see if there are changes or additions you would like to make to the medications for the patient.

Just to recap, you need to:

1. Review the new test results;
2. Revise your differential diagnosis to reflect the new evidence we have received; and
3. Order additional tests you determine to be necessary, based on the revised differential.

I am concerned that Ella has not started responding to the treatments yet. This is extremely urgent, but I’ll be in meetings most of the day. I’ll have my Blackberry with me, so please email me your revised Differential Diagnosis as soon as you can.

Thanks for your help,

Dr. Sophia Campbell