Chapter 7: The Nervous System | Lucy Carmel's Chart Note

Emergency Department Report

Patient Name: Carmel, Lucy
ID Number: 495LC
Examination Date: February 19, 20xx

CHIEF COMPLAINT
Nausea, vomiting, and headache.

HISTORY OF PRESENT ILLNESS
This is an 18-year-old female who was seen by her PCP (primary care physician) early this morning. She has a 5-day history of nausea, vomiting, headache, and elevated temperature with increasing lethargy. She was evaluated and sent to the emergency department for a lumbar puncture to rule out meningitis.

ALLERGIES
None known.

PHYSICAL EXAMINATION
Physical examination reveals a well-developed, well-nourished, somewhat lethargic young female. BP is 110/74, pulse 94, respirations 25, and temperature 101.2. Examination of the neck revealed marked stiffness with rigidity and positive Babinski reflex and Kernig's sign. Cardiac exam is regular in rate and rhythm with no murmurs (atypical, extra sounds heard while examining heartbeat). Lungs are clear bilaterally. During the course of the exam the patient became profoundly lethargic and did not respond appropriately to pain stimuli.

LABORATORY DATA
Lumbar puncture revealed a cloudy fluid that is gram-stain positive for gram-negative cocci (type of bacteria). A CBC (complete blood count) is also consistent for a bacterial process.

IMPRESSION
Acute bacterial meningitis.

PLAN
Request neurological consult for probable acute bacterial meningitis.