DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
PRINCIPAL DIAGNOSIS: Chronic fatigue syndrome.
SECONDARY DIAGNOSES:
1. Essential hypertension.
2. Change in mental status.
PRINCIPAL PROCEDURES: The patient had a lumbar puncture, MRI of the brain, and EEG.
CONSULTATIONS: Nephrology and infectious disease.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who was evaluated initially in the outpatient office due to new onset with difficulty of concentration, poor memory, chills, and tremor which was a significant change from her baseline mental status. The patient had recently visited Austria at the end of March. She did experience an illness on the trip that consisted of fevers, aches, and fatigue. She returned home and began to complain of headaches, memory difficulty, and problems with poor performance with poor concentration. She had outpatient blood work performed by her pediatrician that was reportedly within normal limits but had been unable to attend school consistently since her return from her trip. The patient denied any myalgias but reported significant fatigue with intermittent chills and fever. She denied any rash, and she denied any known ingestions of drug or any illicit drug use.
PAST MEDICAL HISTORY: Negative for any prior hospitalizations or operations.
MEDICATIONS: The patient is on no current medications.
ALLERGIES: No known allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is a (XX)th grade student. She usually achieves A’s and B’s and had done well previously with her school performance.
PHYSICAL EXAMINATION: HEENT: On initial physical examination, the patient had an injected throat. NECK: She had a supple neck with negative Kernig and Brudzinski sign. HEART: She had a regular rate and rhythm with no murmur. LUNGS: Clear to auscultation. ABDOMEN: Soft and nontender with no masses. NEUROLOGIC: On neurologic examination, she was awake, but she was very delayed with her responses with obvious difficulty with processing. She had 3/3 on short-term memory testing, but at times, she was unable to answer some simple questions. Cranial nerves II through XII were intact. On motor examination, she had no drift and did not demonstrate any tremor on examination. She had 5/5 strength. Her deep tendon reflexes were +2 throughout in the bilateral upper and lower extremities with downgoing toes. The patient had normal gait, normal heel-toe walking, and no balance difficulties.
HOSPITAL COURSE: The patient was admitted due to her recent change in mental status, status post viral illness at that time, to rule out meningitis or encephalitis and to determine the possible underlying etiology. The patient was admitted. An MRI scan of the brain was performed, which was within normal limits. A lumbar puncture was also performed; also, CBC, chemistry panel, sedimentation rate, Lyme titer, Epstein-Barr panel, Monospot, urinalysis, urine tox screen, pregnancy test, folic acid level, B12 level, and RPR. She also had an EEG performed during her hospitalization.
The patient’s lumbar puncture had glucose of 74, protein of 18, rbc’s 0, wbc’s of 2. It did not grow anything on culture. Chest x-ray and echocardiogram were within normal limits. RPR was negative. Sedimentation rate was 16. Lyme titer was negative. Her urine tox screen was negative. Thyroid function studies were within normal limits as were the folic acid and B12 levels. Urinalysis was within normal limits. Pregnancy test was negative. The patient did have a positive Epstein-Barr titer with the IgG level of 4.94. The IgM level for the Epstein-Barr was negative. EBNA antibody for IgG was positive at 3.75. She had a negative strep culture of her throat. ANA was positive at 1:40. Lyme titer was negative. Quantitative immunoglobulins were within normal limits.
During her hospitalization, the patient demonstrated borderline blood pressure recordings. She was seen by Dr. John Doe who had recommended an ultrasound of her kidneys, which was within normal limits. She had an EKG, which was also within normal limits. She recommended a low-salt diet and followup as an outpatient. She was also seen by Dr. Jane Doe of infectious disease, who felt that based upon the patient’s presentation and her studies that her illness was a form of chronic fatigue syndrome with a confusional state or change in mental status as a result.
She was scheduled to also follow up with Dr. Jane Doe on an outpatient basis as well as our office, in neurology, as an outpatient. Her EEG also was within normal limits during her hospitalization. The patient was discharged. Followup visit was scheduled with us in two weeks in the outpatient office. The patient’s family was to notify the office sooner if there were any problems. There was also an outpatient consultation arranged with Psychiatry, and the patient was placed on Elavil 25 mg p.o. at bedtime. Side effects were reviewed prior to her discharge.
