العصبية

A 45-year-old woman presented to the emergency department with headache and neck stiffness. Approximately 36 hours earlier, she had awoken with an unremitting, throbbing, generalized head pain, the severity of which she rated as 10 out of 10. It was exacerbated by neck movement, especially neck flexion, and accompanied by chills, photophobia, and nausea without vomiting. She denied fevers.

The patient’s medical history included diabetes mellitus, hypothyroidism, morbid obesity, dyslipidemia, gastroesophageal reflux disease, and chronic low back pain. She had had 4 previous episodes of diagnosed meningitis, treated 2, 8, 12, and 22 years previously; however, she could not recall the details of her hospitalizations and treatments, and records were not available. The patient had no residual deficits from the episodes, but she did recall that one of these episodes had been diagnosed as viral meningitis. She also reported chronic limitation of neck flexion for more than 2 decades and had previously been told that this was because she had extra ribs.

The patient was taking aspirin, metformin, levothyroxine, esomeprazole, lovastatin, and calcium with vitamin D. She had no history of migraines. She denied antecedent trauma, contact with sick people, recent travel outside the country, and outdoor activities, such as camping. Nonetheless, the patient recalled pulling an embedded tick out of her skin 3 weeks before presentation. She had had no symptoms from this and recalled no rash. There were 2 dogs and a cat at her home.

On examination, the patient was alert and oriented. Her heart rate was 70 beats/min (regular rhythm), blood pressure was 110/70 mm Hg while sitting, temperature was 36.1°C, and breath sounds were normal. Findings on abdominal examination were unremarkable. There was no rash or lymphadenopathy. She was intolerant of the room light but had no phonophobia. Speech was normal, and she was able to provide her own history. Cranial nerves II through XII, reflexes, tone, strength, sensation, findings on cerebellar examination, and gait were all within normal limits.

1. Which one of the following physical examination findings would be the most sensitive in the detection of meningeal irritation in this patient?

Brudzinski sign

Kernig sign

Jolt accentuation of headache

Straight leg raise

Babinski reflex