History of present illness:
This is a 19 year old man who was in good health until he noticed 9
days ago that he had muscle aches. Four days ago he developed a fever but
he doesn't recall how high. He developed a severe headache, as well as
a little neck aching and stiffness, so he went to the emergency room. He
was given a diagnosis of "flu", and was treated with ketorolac (Toradol
®). This made the headache better for a while, but it returned. The
headache is severe, and he rates it as "10 on a scale of 1 to 10". The
headache is bilateral periorbital, pounding, with photophobia, phonophobia,
and nausea.
Allergies: None
Medications: Hydrocodone for pain.
Past medical history: Asthma
Family history: Mother suffers from migraines. Other family
members have had hypertension and TIA.
Social: Smokes 1 pack of cigarettes per day. Does not use alcohol.
Uses marijuana.
Physical examination:
Vital signs: Temperature 100 degrees F, Pulse 80 , Respiratory
rate 16 , Blood pressure 120/82 , Weight 65 kg.
General physical exam: Normal except for moderate neck stiffness.
Kernig's and Brudzinski's signs absent.
Neurological exam: Alert and cooperative. Mental status normal.
Fundus examination normal. Cranial nerve, motor, sensory, reflex, coordination
and gait exams normal.
Initial laboratory studies:
CBC and basic metabolic panel were normal.
Course of illness:
Meningitis was suspected, and a lumbar puncture was done. Fluid was
clear. White blood cell count was 459 cells/cu. mm, with 97% lymphocytes.
Red blood cell count was 1. Glucose was 62, protein 44. Gram's stain was
negative. Bacterial and viral cultures were done.
Questions:
1. What is the diagnosis?
2. Can you determine the most
likely etiology?
3. What should be done for the
patient?