History and Physical — Patient 45

History

Present Illness: A six year old African-American boy, previously healthy, presents for evaluation of headache of five days' duration. The headache is described as bifrontal, without nausea or vomiting, visual aura, fever, diplopia or "crossing of eyes." There is no history of recent head or neck trauma, falls, antecedent or current gastrointestinal or respiratory tract infection, or recent or recurrent ear infections. The patient had never experienced a headache of similar nature or severity. His mother initially treated the headache with baby aspirin, which did not produce improvement. He was evaluated at another hospital on the third day of headache, and reportedly had a negative CT scan of the head; at that time, oral acetaminophen was recommended for his headache. His headache persisted, with decreasing oral intake attributed to pain. On the fifth day of symptoms, he was brought to the Texas Children's Hospital emergency room.

In the emergency room, the patient was afebrile, did not appear catastrophically ill, and was reported to have a normal clinical exam, without papilledema. He did not complain of earache on his initial evaluation. Other than aspirin and acetaminophen, he had not ingested any medications or over-the-counter remedies. Crying was not reported to worsen the headache. A lumbar puncture, performed after the administration of midazolam 1 mg, showed an opening pressure of 55 cm water. The patient experienced no agitation or pain during the procedure.

The Neurology Service was consulted for further evaluation and management.

Past Medical History: Immunizations up to date. The patient had completed a course of isoniazid prophylaxis recently for a positive PPD skin test. No history of surgical procedures.

Past Surgical History: None.

Allergies: No known drug allergies.

Medications: Acetaminophen.

Family History: Negative for migraine, seizures, mental retardation or developmental delay. The patient has two siblings who are healthy. No family history of sickle cell disease.

Social History: Normal school performance, with active interest and performance in sports.

Review of Systems: No history of recent weight loss or gain, or of obesity. No recurrent or recent infections, night sweats, fatigue, chest pain, palpitations, dyspnea, arthralgias or arthritis. No history of hematologic disease or of a coagulation disorder. No history of seizures or other neurologic illnesses.

Physical Exam

General: Awake, alert, and cooperative during the examination. The patient is slender, with weight/height in 25th-50th percentile range.

Vital Signs: B.P. 84/39 mmHg with no orthostatic blood pressure or heart rate changes noted; pulse 84/min, regular; temperature 96.4 F.

HEENT: Normocephalic with FOC 51.5 cm (50th percentile). No photophobia was present. No papilledema noted on funduscopic examination. Normal otoscopic examination without any evidence for otitis media. No mastoid tenderness. No oral or mucosal lesions. No neck masses or engorged scalp veins noted. Neck supple without evidence of meningeal irritation.

Chest: Normal to auscultation and percussion.

Cardiovascular: Regular rate and rhythm without murmurs. Peripheral pulses are symmetric and regular.

Abdomen: Soft, without hepatosplenomegaly. Normal bowel sounds.

Extremities: Normal joint range of motion, without joint swelling or pain. No cyanosis, clubbing, or edema.

Skin: No cutaneous lesions noted. No evidence of significant dehydration. No hirsutism.

Neurological Examination

Mental Status: Normal mentation and speech.

Cranial Nerves: Olfaction not tested. Visual acuity 20/40 OU. Fields by bedside confrontation are normal. Full range of extraocular movements, without diplopia. Symmetric and normal facial sensation and movements. Hearing intact to bedside testing. Symmetric and normal elevation of the palate, with normal tongue bulk and movement. Normal strength of head turning and shoulder elevation.

Motor: Normal strength in all four extremities, with normal muscle bulk and tone.

Reflexes: Tendon reflexes present and symmetric throughout.

Sensation: Normal pinprick, light touch, proprioception in all four extremities and trunk. Normal vibration sensation.

Cerebellar: Normal finger-to-nose and rapid alternating movements bilaterally in the arms.

Gait: Normal gait with heel, toe, and tandem walking.

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