Neurology Files

File No: 1


CHART NOTE



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 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’s, Kernig signs.  Chest was clear.  Heart regular in rhythm.  Abdomen was soft.  Neuro:  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 RBCs.  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.


File No:2


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 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 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, 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.  RBCs 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 at 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.