Posted by aBEE M. on 2/22/2013 12:34:00 AM
HISTORY AND PHYSICAL EXAMINATION
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° over the last 6 days. She complains of a 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.
GENERAL: The patient is a well-nourished, well-developed, pale, slightly toxic-appearing white female with photophobia.
VITAL SIGNS: Temperature 100.2°, repeat 98.5. Blood pressure 98/60, pulse 72, respirations 16.
HEENT: Head: Normocephalic, atraumatic. Eyes: Pupils equal, round, react to light. Extraocular movements intact. Funduscopic reveals normal vasculature and sharp disc margins. TMs normal. Nose and throat: Clear.
NECK: 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.
BREASTS: Without masses.
ABDOMEN: Nontender without organomegaly or masses. There is a right upper quadrant surgical scar and a hypogastric surgical scar noted.
PELVIC: Exam not done.
RECTAL: Exam not done.
EXTREMITIES: Without clubbing, cyanosis or edema. There are no skin lesions noted.
NEUROLOGIC: Cranial nerves II through XII 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, CO2 of 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. RBCs are 10 in number.
1. Meningitis – probably viral. If not viral, most likely meningococcal or pneumococcal.
2. History of migraine headache.
PLAN: The 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.3 h. Blood culture is pending as well as culture of the CSF.