PROVISIONAL DIAGNOSIS
Acute bacterial meningitis.
BRIEF HISTORY
The patient is a 3-1/2-year-old male with a 5-day history of nausea, vomiting, temperature elevation, increasing lethargy. He was seen and evaluated in the office on the day of admission and brought to the emergency room for lumbar puncture. This revealed cloudy fluid. Also, a CBC was consistent with a bacterial process.
PHYSICAL EXAMINATION
Blood pressure 92/64, pulse 100, respirations 24, temperature 100.8. HEENT revealed marked stiffness of the neck with nuchal rigidity. Positive Brudzinski, Kernig signs. Chest was clear. Heart regular in rhythm. Abdomen was soft. Neurologic: The patient was fairly lethargic and did not respond appropriately to painful stimuli.
LABORATORY DATA
Lumbar puncture revealed normal pressure. CSF protein 67. WBC 7040 with 98% polys, 2% lymphs, 210 rbc’s. Gram stain positive for gram-negative cocci. CSF glucose 26, serum glucose 96. CBC revealed WBC of 21.9 with 70 segs, 13 bands, 14 lymphs. Hemoglobin 11.6, hematocrit 35.1.
PLAN
Patient to be admitted emergently with probable meningitis.
FOOTNOTE
Line 21. Sign was changed to signs for plural agreement (Brudzinski, Kernig signs).
Line 22. Neuro was expanded to Neurologic for clarity.
Line 31. The 2 different laboratory test results (hemoglobin and hematocrit) were separated for clarity.
No comments:
Post a Comment