Unspecified viral meningitis
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Sulfasalazine / Cephalosporins
 
Attending: ___.
 
Chief Complaint:
___ ADMISSION HISTORY AND PHYSICAL
.
.
PCP: ___. ___
.
.
CC: MENINGITIS
.

 
Major Surgical or Invasive Procedure:
LUMBAR PUNCTURE IN ER ___
 
History of Present Illness:
___ old male with h/o remote staph infection in infancy, S-J 
syndrome to either bactrim/cefixime many years ago, recurrent 
strep throat is here with headache and fever. Pt has been 
stressed out due to finals and had some intermittent HA for past 
couple weeks. However 3days ago he came home from school with 
severe HA and fever of 102. He went to sleep and felt better the 
next day. Yesterday afternoon, the HA returned and was very 
severe. Described as head fullness worse than he has ever had 
(has had mild HA with fevers in past) and also had eye pain 
(with movement, not photophobia). Also had fever again yesterday 
to 101-102. Had mild sore throat but nothing like his usual 
strep symptoms. Took tylenol and went to bed. Woke up this am 
with persistant HA and fever so came to ER. No sick contacts. No 
neck stiffness. No confusion/lethargy. No travel. No skin rash 
or joint complaints. No sore throat or cough today. Other than 
HA and fever, no other complaints. 
Called PCP this am, ___ to ER for LP
.
In ER, underwent LP, c/w viral meningitis. Started on Abx for 
concern for early bacterial meningitis as well. Given possible 
Cephalosporin/sulfa allergies, given Vanc/Doxy with plan to add 
chloramphenicol.  Is sad about missing school and review for his 
finals. 
 
Past Medical History:
staph skin infection in infancy
S-J syndrome to either bactrim or cefixime
recurrent strep throat ___
 
Social History:
___
Family History:
no FH of recurrent infections
 
Physical Exam:
Physical Exam: 
Vitals on arrival to ER: 97.7  111/62  80  18  100%RA
Vitals on arrival to floor: 97.8  ___  64  16  98%RA 
Gen: pleasant, thin male, in NAD
Eyes: EOMI, anicteric
ENT: o/p clear w/o exudates, mmm
Neck: no LAD
CV: RRR, no m, nl S1, S2
Resp: CTAB, no crackles or wheezes
Abd: soft, nontender, nondistended, +BS, no HSM
Lymph: no cervical, axillary, inguinal LAD
Ext: no edema, good peripheral pulses, no cyanosis
Neuro: A&OX3, CNII-XII intact, normal gait, strength equal b/l 
___, intact sensation, reflexes 2+ ___, neg Kernig/neg 
Brudzinski
Skin: warm, NO rashes and no petechia
psych: appropriate
.
.
On discharge
Vitals:Tm 99.4  Tc 97.9  ___  18 98%RA
Pain: ___ eye pain
Access: PIV
Gen: nad
HEENT: anicteric, o/p clear, mmm
Neck: no LAD
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, +BS, no HSM
Ext; no edema
Neuro: A&OX3, remains at baseline-nonfocal
Skin: no rash
psych: appropriate
.

 
Pertinent Results:
wbc 5.8 wiht 64%N
hgb ___
plt 158
.
Chem: BUN/creat ___
LFTs wnl
.
INR 1.4
.
LP 
wbc 110, 90 with 8%PMN, 84%Lymph, 8% Mono
RBC 3, 3
Gluc 51
T pro 50
Lyme pending***
CSF ___ neg
CSF Cx NTD
Blood CX X2 NTD
.
.
Imaging/results: 
NONE

 
Brief Hospital Course:
___ old male admitted with 3days of HA and fever. Underwent 
LP in ER with findings of meningitis.  LP showed lymphocytic 
predominence and patient clinically looked very well so likely 
aseptic meningitis. However, there was concern that this could 
also represent early bacterial meningitis, thus he was covered 
empirically with Abx.  Pt had a h/o severe allergy (S-J 
syndrome) to either cefexime/bactrim so after discussion with 
ID, we covered for bacterial meningitis with vanc, doxy PO, 
chloramphenicol IV q6. No evidence of encephalitis so less 
likely HSV so acyclovir not started (and we did not check for 
this). The ER sent off lyme serologies in CSF fluid and this is 
PENDING at time of discharge (communicated to PCP). Our 
suspicion for this was low.  After the cultures were negative 
for 48hours, these were stopped. Pt was told to continue 
supportive care for his Aseptic Meningitis with rest, fluids, 
tylenol. He remained afebrile here. He had a mild HA that was 
better with tylenol and mild eye pain w/o evidence of 
conjunctivits/episcleritis. He was discharged in good condition. 
 
 
Medications on Admission:
Preadmission medications listed are correct and complete.  
Information was obtained by Patient.
1. Acetaminophen 650 mg PO Q6H:PRN fever 

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Aseptic meningitis
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
You were admitted for fevers and headache that ocurred over a 
couple days. You underwent Lumbar puncture which showed you had 
meningitis. Initially we covered you with IV antibiotics in the 
case this was early bacterial meningitis (which can be 
dangerous). However, your cultures from the spine fluid and 
blood remained negative for 48hours, so this was more likely 
ASEPTIC (aka Viral) meningitis. This is treated with supportive 
care like any viral illness with rest, fluids, tylenol as 
needed. 
You will not be discharged on any antibiotics
 
Followup Instructions:
___

{'headache': ['Unspecified viral meningitis'], 'fever': ['Unspecified viral meningitis'], 'eye pain': ['Unspecified viral meningitis']}