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The Rational Clinical Examination |

Does This Adult Patient Have Acute Meningitis?

John Attia, MD, PhD; Rose Hatala, MD, MSc; Deborah J. Cook, MD, MSc; Jeffrey G. Wong, MD
JAMA. 1999;282(2):175-181. doi:10.1001/jama.282.2.175.
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Context Early clinical recognition of meningitis is imperative to allow clinicians to efficiently complete further tests and initiate appropriate therapy.

Objective To review the accuracy and precision of the clinical examination in the diagnosis of adult meningitis.

Data Sources A comprehensive review of English- and French-language literature was conducted by searching MEDLINE for 1966 to July 1997, using a structured search strategy. Additional references were identified by reviewing reference lists of pertinent articles.

Study Selection The search yielded 139 potentially relevant studies, which were reviewed by the first author. Studies were included if they described the clinical examination in the diagnosis of objectively confirmed bacterial or viral meningitis. Studies were excluded if they enrolled predominantly children or immunocompromised adults or focused only on metastatic meningitis or meningitis of a single microbial origin. A total of 10 studies met the criteria and were included in the analysis.

Data Extraction Validity of the studies was assessed by a critical appraisal of several components of the study design. These components included an assessment of the reference standard used to diagnose meningitis (lumbar puncture or autopsy), the completeness of patient ascertainment, and whether the clinical examination was described in sufficient detail to be reproducible.

Data Synthesis Individual items of the clinical history have low accuracy for the diagnosis of meningitis in adults (pooled sensitivity for headache, 50% [95% confidence interval {CI}, 32%-68%]; for nausea/vomiting, 30% [95% CI, 22%-38%]). On physical examination, the absence of fever, neck stiffness, and altered mental status effectively eliminates meningitis (sensitivity, 99%-100% for the presence of 1 of these findings). Of the classic signs of meningeal irritation, only 1 study has assessed Kernig sign; no studies subsequent to the original report have evaluated Brudzinski sign. Among patients with fever and headache, jolt accentuation of headache is a useful adjunctive maneuver, with a sensitivity of 100%, specificity of 54%, positive likelihood ratio of 2.2, and negative likelihood ratio of 0 for the diagnosis of meningitis.

Conclusions Among adults with a clinical presentation that is low risk for meningitis, the clinical examination aids in excluding the diagnosis. However, given the seriousness of this infection, clinicians frequently need to proceed directly to lumbar puncture in high-risk patients. Many of the signs and symptoms of meningitis have been inadequately studied, and further prospective research is needed.

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meningitis

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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The Rational Clinical Examination
Make the Diagnosis: Meningitis, Adult

The Rational Clinical Examination
Original Article: Does This Adult Patient Have Acute Meningitis?

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