CNS Infections — DCE Clinical Case

Systematic examination routine

1. General inspection first: conscious state and engagement (the single most important observation — confusion redirects you from meningitis toward encephalitis), photophobia behaviour, rash on the trunk and limbs (press for blanching — a non-blanching purpuric rash is meningococcaemia until proven otherwise) ^[1].
2. Vital signs: temperature, heart rate, blood pressure, respiratory rate, oxygen saturation — sepsis physiology changes the urgency, not the examination ^[1].
3. Higher function screen: orientation to person/place/time, attention (serial sevens or months reversed), and a brief language screen — dysphasia localises, confusion globalises.
4. Meningeal signs: neck stiffness on passive flexion, Kernig sign (hip flexed to 90°, pain on knee extension), Brudzinski sign (hips flex on neck flexion) — then state their limitation aloud: these signs are traditional but insensitive, and their absence does not exclude meningitis ^[1].
5. Fundi: papilloedema — the finding that gates the LP decision via the Hasbun criteria ^[2].
6. Cranial nerves and a rapid motor screen: focal signs (again Hasbun-relevant), and ears/throat for a contiguous source ^[2].