Neurology Case Study

CHIEF COMPLAINT

Headache for 6 days.

HISTORY OF PRESENT ILLNESS

The patient is a 31-year-old gravida 3, para 3, with complaint of headache and fever to 103 degrees over the last 6 days.  She complains of the headache being bandlike in nature and different than her usual migraine headaches, which are left-sided in nature.  The patient had been feeling better yesterday without headache or fever, and things got worse again today.  She reports nausea without vomiting but has had photophobia.  She denies history of drug abuse, foreign travel, or meningitis exposure.

PHYSICAL EXAMINATION

VITAL SIGNS:  Temperature 100.2, repeat 98.5.  Blood pressure 98/60, pulse 72, respirations 16.

GENERAL:  The patient is a well-nourished, well-developed, pale, slightly toxic-appearing white female with photophobia.

HEENT:  Head is normocephalic, atraumatic.  Pupils equal, round, react to light.  Extraocular movements intact.  Funduscopic reveals normal vasculature and sharp disk margins.  TMs normal.  Nose and throat clear.

NECK:  Neck is without masses.  There is no nuchal rigidity.  There is slight tenderness on extreme anterior flexion.

CORONARY:  Regular rate and rhythm without murmur, gallop, or rub.

LUNGS:  Lungs are clear.

BREASTS:  Without masses.

ABDOMEN:  Nontender, without organomegaly or masses.  There is a right upper quadrant surgical scar and hypogastric surgical scar noted.

PELVIC:  Pelvic exam not done.

RECTAL:  Rectal exam not done.

EXTREMITIES:  Without clubbing, cyanosis, or edema.  There are no skin lesions noted.

NEUROLOGIC:  Cranial nerves 2-12 intact.  The patient is alert and oriented and moving all extremities.

LABORATORY

CBC:  White blood count 13,000 with 54 polys, 5 bands, 35 lymphs, 3 monos, 3 eos.  Hematocrit 43.4.  Urinalysis:  Specific gravity 1.010.  No white cells or red cells.  Electrolytes:  Sodium 134, potassium 3.7, chloride 102, C02 28.  CSF:  Protein 44, glucose 59.  Serum glucose 99.  Gram stain of CSF:  Without organisms seen.  Cell count:  53 white cells with 65% lymphs, 35% polys.  Rbc’s are 10 in number.

IMPRESSION

1. Meningitis — probably viral.  If not viral, most likely meningococcal or pneumococcal.

2. History of migraine headache.

PLAN

Patient will be admitted to the medical floor.  She will be placed in respiratory isolation for at least 24 hours.  She will be given IV penicillin G 3 million units IV piggyback q.3h.  Blood culture is pending as well as culture of the CSF.

FOOTNOTE

Line 20 (Page 1).  Exam was expanded to Examination in the heading.

Line 27 (Page 1).  Alternative:  Disc.

Line 40 (Page 1).  There is was edited to there are for
subject-verb agreement.

Line 42 (Page 1).  2 through 12 is preferably written as 2-12.

Line 45 (Page 1).  Lab was expanded to Laboratory in the heading.

Line 2 (Page 2).  Here rbc refers to red blood cells.

Line 12 (Page 2).  The slang term pen G was translated as penicillin G.  The dictated q.3 hours was changed to q.3h for uniformity.