EXAMPLE
Nimisha Shah, M.D.
HISTORY AND PHYSICAL
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PRIMARY CARE PHYSICIAN: Aslam Barra, M.D. (cc to this physician)
CHIEF COMPLAINT: Headache, nausea, and vomiting.
HISTORY OF PRESENT ILLNESS: The patient is 51-year-old middleaged female with no significant past medical history. She
presented to the ER with chief complaints of diffuse throbbing
headache of intermittent character for 5 days. It was
precipitated by a flu like illness 2 weeks ago. She also noted a
history of nausea and frequent episodes of vomiting, 10 to 12
times since yesterday. She denies any abdominal pain. She was
evaluated in the ER on December 31, 2005, for similar symptoms.
Initial workup, including CT of brain was negative. She was
discharged home on oral medication, Soma. However, she noted
worsening of headache and presented to the ER today. On arrival
to the ER, she was mildly febrile, and otherwise hemodynamically
stable, alert, and oriented x3. CBC and CMP were unremarkable.
Lumbar puncture revealed lymphocytic leukocytosis and elevated
protein suggestive of viral meningitis. She received IV fluids
and a dose of Rocephin in the ER. She was admitted for further
management to the med/surg floor.
REVIEW OF SYSTEMS: She does give history of malaise, anorexia,
and posterior neck pain for the last 3 to 4 days. There is no
history of lethargy, drowsiness, seizures, abdominal pain,
diarrhea, or photophobia.
PAST MEDICAL HISTORY: Cesarean section.
HOME MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is married and a Gilroy resident. She has 3
kids. She works at Christopher Ranch. She denies smoking,
alcohol, or other substance abuse.
FAMILY HISTORY:
Noncontributory.
PHYSICAL EXAMINATION: VITAL SIGNS: T. max 99, pulse 66,
respirations 20, blood pressure 163/84, weight 215 pounds.
GENERAL: The patient is a 51-year-old middle-aged slightly obese
female lying on the bed without apparent acute distress but
mildly sedated with medication. HEENT: Atraumatic,
normocephalic, normal pharynx mucosa. Eyes: Pupils are equal and
reactive to light and accommodation. Extraocular movements
intact. NECK: No JVD noted. Carotid bruits absent. Lymph nodes
nonpalpable. LUNGS: Air entry is equal on both sides. No wheezing
or crackles heard. CARDIOVASCULAR: S1, S2, regular. No gallops or
murmur heard. ABDOMEN: Bowel sounds present, soft. Minimal left
lower quadrant tenderness noted. However, guarding, rigidity, and
rebound tenderness absent. CENTRAL NERVOUS SYSTEM: Drowsy but
arousable. Oriented x3. No obvious focal deficits noted. Cranial
nerves II-XII intact. Coordination normal. EXTREMITIES: No pedal
edema. Peripheral pulses noted. Cyanosis and clubbing absent.
Homans sign negative.
PERTINENT LABORATORY FINDINGS: CSF and initial tube color was
hemorrhagic; tube #4 appears clear. WBC 680, polys 35,
lymphocytes 55, eosinophils 6, RBC 70. Meningitis antigen panel
including streptococcal pneumonia, group B, streptococcal
antigen, influenza hemophilia negative, Gram-stain, no organisms
noted, glucose 28, and protein 147. WBC 9.2, hemoglobin 13.4,
hematocrit 41, platelets 319, sodium 140, potassium 4.2, chloride
99, BUN 31, glucose 131. Total bilirubin 0.4, AST 45, ALT 35,
amylase 73, lipase 80. CT of brain done on December 31, 2005 is
unremarkable.
ASSESSMENT: This patient is a 51-year-old middle-aged female with
history of diffuse headache, nausea, vomiting. She is noted to
have lymphocytic leukocytosis in cerebrospinal fluid along with
elevated protein, suggestive of acute viral meningitis. She is
also noted to have mild dehydration secondary to gastritis,
requiring IV hydration and supportive treatment.
PLAN:
1.
Admit to med/surg.
2.
IV hydration with normal saline.
3.
IV Phenergan p.r.n. for nausea and vomiting and proton pump
inhibitor, Protonix.
4.
Tylenol p.r.n.
5.
Pain control with Demerol p.r.n.
6.
Obtain cerebrospinal fluid PCR for vital studies, antiviral
being more common etiology, not requiring any antiviral
treatment at this moment. Will also follow PCR studies for
HSV and if HSV, EBV, and VCV are positive may consider
acyclovir.
7.
Obtain blood cultures, urine culture and sensitivity.
8.
Obtain chest x-ray.
9.
Obtain infectious disease consult with Dr. Charney in a.m.