Sample Name: Gen Med Consult - 24
Description: Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Headache and pain in the neck and lower back.
HISTORY OF PRESENT ILLNESS: The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.
Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.
Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.
On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.
Past Medical History: HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.
PAST SURGICAL HISTORY: Excisional lymph node biopsy (9/03).
FAMILY HISTORY: There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.
SOCIAL HISTORY: Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .
ALLERGIES: Sulfa (rash).
REVIEW OF SYSTEMS: The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.
VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.
GEN: Well developed man in no apparent distress. Alert and Oriented X 3.
HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.
NECK: Stiff, difficulty with neck flexion; no lymphadenopathy
LUNGS: Clear to auscultation bilaterally.
ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.
EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.
BACK: No point tenderness to spine
NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.
SKIN: warm, no rashes, no lesions
C-spine/lumbosacral spine (11/30): Within normal limits.
CXR (12/8): Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.
CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.
HOSPITAL COURSE: The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.
Keywords: general medicine, castleman’s disease, chop chemotherapy, ventriculomegaly, excisional lymph node biopsy, excisional lymph node, excisional lymph, node biopsy, lymph node, neck, aids, chop, chemotherapy, node, headaches, lymphadenopathy,