Encounter date: ____October 10, 2022___________________
Patient Initials: B. L. Gender: M Age: 28 Race: White Ethnicity: European
Reason for Seeking Health Care: Consultation and Treatment of a persisting health condition
HPI: The patient complained of severe neck pains and muscle strains. According to the patient, he was experiencing stiff neck pains. Liam rated the pain on a scale of 6/10 and confirmed its persistence over the past 2 weeks. The pain was mostly in the morning and evening. Since its onset, Liam has been using painkillers and warm water to numb the pain. According to the patient, the pain moves the neck upward, causing him to have strong headaches. Upon inquiry, neither Liam nor any family member had ever undergone any form of surgery originating from neck pain.
Allergies (Drug/Food/Latex/Environmental/Herbal): The patient is allergic to proteins, especially red meat. The food causes physical harm to Liam; any time he tries eating, the body reacts negatively. Meat causes tissue and skin swelling, diarrhea, runny nose, and anaphylaxis in the patient. According to Liam, he experiences environmental allergies when in dusty and extra cold places. Liam sneezes, develops itchy eyes, and fatigues when in a dusty region. Liam did not report latex, drug, and herbal allergies.
Current perception of Health: Fair
Past Medical History
- Major/Chronic Illnesses: Meningitis
- Trauma/Injury: N/A
- Hospitalizations: The patient was last hospitalized 2 months ago. Liam was experiencing breathing problems when he was rushed to an inpatient-based facility in the city. He stayed at the healthcare institution for 3 days while undergoing treatment. The first day was hectic; however, the patient reported positive changes after interacting with a doctor on the third day. After diagnosis with spinal cord disease, Liam becomes prone to neck pains.
Past Surgical History: N/A
Medications: Liam has been put in a primary care treatment scheme following his diagnosis of bacterial meningitis. To reduce the complications of seizures and swelling of the brain, the patient has been provided with corticosteroids and intravenous antibiotics. The medication will facilitate the healing process and reduction of inflammation and pains in the neck region. The immediate hospitalization of the patient enabled the detection of the infection through numerous screening techniques. Liam will take the drugs for 10 days and return to the hospital for a checkup.
Family History: The patient’s father had undergone minor surgery on the spine in his adolescence. He was affected by polio but survived. In addition, the youngest sibling of the family has asthma, and she regularly visits hospitals for a checkup. There are no aligning medical conditions inherited in the family lineage.
Social history: Liam is single and lives with his father in uptown. He works as a computer scientist in a private organization located in New York City. The patient has enrolled in a recreational sports activity that keeps him fit during weekends and holidays. Liam does not smoke tobacco or marijuana. However, he drinks alcohol occasionally, maybe during special events in his life and career line. The patient holds a master’s degree in computer science and plans to register for a Ph.D. program. He is sexually active with zero complications to STIs and HIV/AIDS symptoms. Although Liam is mentally stable, he once experienced workplace depression from organizational pressure. The client reported no suicidal thoughts during examinations.
Lives: Single family House/Condo/ with stairs: Single family House
Marital Status: Single
Employment Status: Employed
Current/Previous occupation type: Computer Scientist
Exposure to: Smoking: N/A ETOH: YES Recreational Drug Use: YES
Sexual orientation: Heterosexual Sexual Activity: between two persons Contraception Use: N/A
Family Composition: Family/Mother/Father/Alone: Family
Health Maintenance
Screening Tests: Lumbar puncture, blood test, and CT scan
Exposures: Infectious agents, radiation, and extreme weather
Immunization HX: Meningococcal conjugat and MenQuadfi vaccines
Review of Systems:
- General: Decreased appetite, weight loss, body weakness, and shivering.
- HEENT: Increased intracranial pressure, sinusitis, predilection, and otitis
- Neck: Neck stiffness, nuchal rigidity, swollen glands, and subarachnoid hemorrhag
- Lungs: cough, chest pains, and shortness of breath.
- Cardiovascular: Wheezing and blue fingers.
- Breast: CLEAR
- GI: Change of Appetite and Nausea
- Male/female genital: Dribbling, frequent urination, and urgency to urinate.
- GU: hypotonic neurogenic bladder
- Neuro: numbness, seizures, and incoordination
- Musculoskeletal: Neck swelling, arthritis, and severe sprains.
- Activity & Exercise: mood swings, isolation, and anxiety.
- Psychosocial: Partial hearing loss and reduced concentration.
- Derm: Skin rash and pinprick marks in the body
- Nutrition: Hives, hay fever, and swelling of the tongue.
- Sleep/Rest: Sleep problems
- LMP: N/A
- STI Hx: Clear urine
Physical Exam
BP_____72/48mmHg___TPR_ 36.6°C____ HR: _100 beats per minute___ RR: _22 breaths per minute___Ht. __1.75m___ Wt. 72kg ______ BMI (percentile) ___18.5-24.9kg/m2__
- General: Weight loss
- HEENT: Papilledema, mastoiditis, and sinusitis
- Neck: neck stiffness
- Pulmonary: chest pain and high fever
- Cardiovascular: heart murmur
- Breast: N/A
- GI: food intolerance
- Male/female genital: Clear urine
- GU: atonic neurogenic bladder
- Neuro: muscle spasm
- Musculoskeletal: decreased joint movement
- Derm: pale skin
- Psychosocial: memory loss
- Misc. inflammation of inner tissues around the neck
Significant Data/Contributing Dx/Labs/Misc.________________________
Plan:
- Differential Diagnoses:
1. Central nervous system vasculitis
2. Meningeal carcinomatosis
3. Meningeal inflammation
- Principal Diagnoses:
1. non-infectious meningitis
2. viral meningitis
Plan:
- Diagnosis: Bacterial meningitis
- Diagnostic Testing: A blood test
- Pharmacological Treatment: Intravenous antibiotics and corticosteroids.
- Education: Antibiotic therapy and treatment models must be incorporated after the conduction of the lumbar test.
- Referrals: NYU Langone Hospitals
- Follow-up: Regular medical checkups, random imaging, blood, and physical exams.
- Anticipatory Guidance: Live a healthy lifestyle, exercise regularly and keep off cold and dusty places.
- Diagnosis Bacterial meningitis
- Diagnostic Testing: Lumbar puncture
- Pharmacological Treatment: Ceftriaxone and cefotaxime drugs
- Education: Consistency and time management in drug intake
- Referrals: Lenox Hill hospital
- Follow-up: Physical exams after 2 weeks of treatment
- Anticipatory Guidance: Exercise regularly
Signature (with appropriate credentials): __________________________________________
Dr. Shem Thompson
Cite current evidenced-based guideline(s) used to guide care (Mandatory) The primary treatment for bacterial meningitis occurs through the admission of four cefotaxime of 50mg/kg every 6 hours (Deliran et al., 2020). In addition, Mintegi et al. (2020) suggest that the prescription of ceftriaxone of 75mg/kg every 12 hours up to 4gram per day can help to cure spinal cord disease. According to El Kareh et al. (2020), treating bacterial meningitis takes place by applying a primary care system that follows a diagnosis conducted by neurologists. Lumbar puncture enables medical specialists to test the sugar levels and red and white blood cells and starts with the cerebrospinal fluid collection. The blood test enhances the accuracy of the doctor to determine the cause of meningitis.
DEA#: 101010101 STU Clinic LIC# 10000000
Tel: (000) 555-1234 FAX: (000) 555-12222
Patient Name: (Initials) B. L.
Age: 28
Date: October 10, 2022
RX Bacterial meningitis
SIG: Zocor 10mg
Dispense: 90 Refill: Zero times
Δ No Substitution
Signature: ____________________________________________________________
References
Deliran, S. S., Brouwer, M. C., Coutinho, J. M., & Beek, D. V. (2020). Bacterial meningitis complicated by cerebral venous thrombosis. European Stroke Journal, 5(4), 394-401. Web.
El Kareh, A., El Hage, S., Safi, S., Assouad, E., Mokled, E., & Salameh, P. (2020). Epidemiology of bacterial meningitis in Lebanon from 2011 to 2019. Journal of Clinical Neuroscience, 81, 32-36. Web.
Mintegi, S., García, S., Martín, M. J., Durán, I., Arana-Arri, E., Fernandez, C. L., Benito, J., & Hernández-Bou, S. (2020). Clinical prediction rule for distinguishing bacterial from aseptic meningitis. Pediatrics, 146(3). Web.