**1. Introduction**

#### **1.1. Initial approach**

It is important to follow a structured systematic approach to ensure good clinical care of the patient and to aid diagnosis. In an acute situation, the patient's airway, breathing and circu‐ lation must be assessed. Therefore, a Primary survey is undertaken and for this an ABCD approach is employed.

Determining the patency of the airway is crucial for the survival of the patient. In the general assessment of airway patency a clinician must observe the face and the neck. Abnormalities in the jaw mouth and neck must be noted as these could lead to airway compromise and future complications. Speaking to the patient for example by asking their name and observing their response, such as able to communicate in full sentences is a good indicator of unobstructed airways. Changes in vocalisation can be due to Asthma, COPD, emboli, oedema or even pneumonia. If any of these conditions are suspected a definitive diagnosis must be obtained as any of these could lead to further deterioration of the patient.

The second stage of the primary survey is the assessment of breathing. We begin with observation of the patient. Looking for signs of respiratory distress is important and failure to recognise this can lead to fatal consequences. Signs of respiratory distress can be the use of accessory muscles or changes in chest movement and in some cases even both.

Observation of the chest for any deformity is important but systemic observation is crucially important as well because it can show signs of cyanosis. At this point the respiratory rate needs to me measured. Then proceed to auscultate the chest and then end in percussion. Oximetry is also undertaken to determine the patient's oxygen saturations.

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The third step in the process is an assessment of the circulatory system. This is a multidimen‐ sional assessment and many factors must be taken into account. As part of the circulatory assessment, examination of the extremities is undertaken to determine if they are warm or cool as a way of assessing perfusion. Next press the nail bed for 5 seconds and if the refill is less than 2 seconds the capillary refill time is normal[1]. Now position the patient at a 45 degree angle and observe the filling of the jugular vein. This is an indicator of the Jugular Venous Pulse (JVP) and in a healthy person the filling should be less than 3cm[2].

**Pathogen Incubation** HSV 2-12 days1 West Nile virus 1-6 days2 JE 5-15 days3 EBV 30-50 days4 Mycoplasma 7-21 days5 Bartonella henselae 7-14 days6 syphilis 9-60 days1

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**Aetiology Fever characteristic** HSV Mild pyrexia2 West Nile virus Mild pyrexia3 JE Mild pyrexia4

Tick borne encephalitis Relapsing- biphasic5 Toxoplasmosis Gondi Relapsing 1:page 873 Bartonella henesle Mild pyrexia 1: page 872

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**Table 2.** Fever characteristics of the various aetiological agents of encephalitis.

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5. Epidemiology of Mycoplasma pneumoniae Infection in Families : Hjordis M. Foy, MD; J. Thomas Grayston, MD; George E. Kenny, PhD; E. Russell Alexander, MD; Ruth McMahan, MN : JAMA. 1966; volume 197( number11): pages

6. The expanding spectrum of Bartonella infections: I. Bartonellosis and trench fever: BASS, JAMES W. MD; VINCENT, JUDY M. MD; PERSON, DONALD A. MD : Paediatric Infectious Disease Journal: January 1997 - Volume 16 - Issue 1 -

**Table 1.** There is an overlap in the incubation period of the various aetiological agents of encephalitis.

EBV 38 - 40oC in the first week 1:pages 871-872 Mycoplasma Morning temperature spikes 1: page 871

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2. Herpes simplex virus infection: Dr Richard WhitleyMD, Bernard Roizman ScD: the Lancet : volume 357: Issue 9267,

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The Clinical Management of the Patient with Encephalitis

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William K.

The clinician should then proceed to measure the blood pressure and auscultate the heart for murmurs; if an abnormality is suspected an ECG should be performed. After these vital steps are done the clinician should move to the lower extremities. The clinician should start with palpating the peripheral pulses; femoral, popliteal and posterior tibial artery as well as the arteries of the upper limbs. Examination of the calf muscles should also be undertaken for DVT[3]. IV access should be obtained as soon as possible if there are signs of haemodynamic compromise.

Assessment of disability is the last step of primary assessment. The AVPU score can be calculated or a calculation of the Glasgow coma scale. Pupillary light reflex and posturing can indicate if there is neurological damage and the severity of encephalitis. A measurement of capillary glucose can also be performed in this stage.
