DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
CHIEF COMPLAINT: Headache for two days.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American female with a past medical history of asthma, who presented to the ER with a complaint of headache for two days. The pain started in the frontal area with radiation to the occipital region. The pain is 10/10 in intensity, worse with movement and bright light. The pain is not relieved with Advil that the patient took at home. The patient admits to nausea, dizziness, and fever with the pain as well as some neck discomfort. The patient also said that she had a history of sinus headache. The patient denies vomiting, recent cold or sore throat.
PAST MEDICAL HISTORY: Asthma; the last attack was 12 years ago.
PAST HOSPITALIZATIONS: None.
ALLERGIES: NKDA.
CURRENT MEDICATIONS: Advil and Claritin.
SOCIAL HISTORY: The patient denies alcohol. She denies smoking. The patient currently lives with her family.
FAMILY HISTORY: The patient’s mother has a history of diabetes. Her father has history of high blood pressure.
REVIEW OF SYSTEMS: Noncontributory, except for photophobia and nausea.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission, temperature 100.2 degrees, pulse 84, respirations 16, blood pressure 134/90, pain level 10/10, and O2 saturation 98% on room air. GENERAL APPEARANCE: The patient is a (XX)-year-old African-American female, alert and oriented x3, in no acute distress with complaint of headache. SKIN: There is no rash. HEENT: Head: Normocephalic and atraumatic. There is no tenderness. Eyes: Pupils are equal and reactive to light and accommodation. Extraocular muscle movements are intact. Ears: No discharge. External canals are patent. Nose: No discharge. No polyps. Throat: No exudates. Mucosa is moist and pink. NECK: Supple. No stiffness. Mild decreased range of motion on forward bending. No lymphadenopathy. CHEST: Symmetrical. HEART: S1 and S2, no murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. MUSCULOSKELETAL: Full range of motion of extremities. There is no edema, no clubbing. Pulses are palpable. NEUROLOGICAL: Sensory intact. Reflexes are 2+ bilaterally and intact. Motor strength is intact, 5/5 in upper and lower extremities bilaterally. Cranial nerves II through XII are intact. The patient has some mild ataxia on walking.
LABORATORY DATA: On admission, WBC 10,400, hemoglobin 11.6, hematocrit 34.2, and platelets 266,000. MCV 73.4, MCHC 34, RDW 19, segs 80, lymphocytes 16, and monocytes 3.
HOSPITAL COURSE: The patient was admitted for intractable headache, rule out aseptic meningitis. CAT scan of the head was done, and preliminary report was negative. Lumbar puncture was done on the day of admission. CSF fluid culture was sent. The patient was given pain medication for the headache. She also received IV fluids. Pain medication includes Toradol 30 mg IM every 8 hours and morphine sulfate 2 mg IV every 4 hours as needed. During the hospital stay, the patient’s condition improved greatly, and she was discharged to home.
MEDICATIONS GIVEN:
1. Ferrous sulfate 325 mg twice daily.
2. Motrin 400 mg every 4 hours as needed.
PRINCIPAL DISCHARGE DIAGNOSIS: Aseptic meningitis.
OTHER DIAGNOSES:
1. Iron-deficiency anemia.
2. Asthma.
DISCHARGE INSTRUCTIONS: The patient will follow up with her medical doctor on MM/DD/YYYY at 8:30 in the morning.
