Medical Assessment Form (PA 635)

Medical Assessment Form Patient Name: John Smith Date of Assessment: 1 November 2024 DOB: 15/03/1978 Age: 46 Gender: Male Reason for Visit: New onset severe headache, photophobia, and neck stiffness. Patient reports symptoms started suddenly 2 days ago and have progressively worsened. History of Present Illness: Patient is a 46-year-old male presenting with a 2-day history of severe, throbbing headache, primarily frontal and temporal, rated 8/10 at its worst. Associated with marked photophobia and mild phonophobia. Also complains of significant neck stiffness and pain, making head movements difficult. Denies recent trauma, fever, rash, or changes in vision. No prior history of similar headaches. He tried over-the-counter paracetamol with minimal relief. States he feels generally unwell and fatigued. Past Medical History: Hypertension (diagnosed 5 years ago, well-controlled with medication), seasonal allergies. Past Surgical History: Appendectomy (2000). Medications: Lisinopril 10mg OD, Cetirizine 10mg OD. Allergies: Penicillin (hives). Family History: Father with hypertension and type 2 diabetes. Mother with migraine headaches. No family history of autoimmune diseases or neurological conditions. Social History: Occupation: Accountant Alcohol Use: Occasional social drinking (2-3 units per week). Smoking Status: Non-smoker. Illicit Drug Use: Denies. Diet: Balanced. Exercise: Moderate, 3 times per week. Travel History: No recent international travel. Review of Systems: General: Fatigue, malaise. HEENT: Headache, photophobia, neck stiffness. Denies visual changes, hearing loss, sore throat, or nasal congestion. Cardiovascular: Denies chest pain, palpitations, or oedema. Respiratory: Denies cough, dyspnoea, or wheezing. Gastrointestinal: Denies nausea, vomiting, diarrhoea, constipation, or abdominal pain. Genitourinary: Denies dysuria, frequency, or urgency. Musculoskeletal: Neck stiffness and pain. Denies joint pain, swelling, or muscle weakness. Neurological: Severe headache, photophobia, neck stiffness. Denies numbness, tingling, weakness, seizures, or loss of consciousness. Dermatological: Denies rash, itching, or skin lesions. Psychiatric: Denies anxiety, depression, or suicidal ideation. Physical Examination: General: Alert and oriented, appears uncomfortable, guarding neck movements. Vital Signs: BP 130/85 mmHg, HR 78 bpm, RR 16 bpm, Temp 37.2°C, SpO2 98% on room air. HEENT: Pupils equal, round, reactive to light. EOMI. Fundoscopy unremarkable. Oropharynx clear. Tympanic membranes intact. Neck stiff with limited range of motion, positive Brudzinski's and Kernig's signs. Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs. Peripheral pulses intact. Respiratory: Clear to auscultation bilaterally, no wheezes or crackles. Gastrointestinal: Abdomen soft, non-tender, non-distended. Bowel sounds present. Neurological: Cranial nerves II-XII intact. Motor strength 5/5 bilaterally in all extremities. Sensation intact to light touch and pinprick. Deep tendon reflexes 2+ and symmetrical. Negative Romberg. Gait steady. Assessment: 46-year-old male with new onset severe headache, photophobia, and neck stiffness with positive meningeal signs. High suspicion for meningitis (bacterial or viral) or subarachnoid haemorrhage. Given acute onset and severity, urgent investigation is warranted. Plan: 1. Lumbar Puncture for CSF analysis (cell count, protein, glucose, culture, PCR). 2. CT head without contrast immediately to rule out mass lesion or haemorrhage before LP. 3. Bloods: FBC, U&Es, CRP, ESR, Blood cultures. 4. Start empiric broad-spectrum antibiotics (e.g., Ceftriaxone, Vancomycin) and Dexamethasone after blood cultures, pending LP results. 5. Admit to hospital for close monitoring and further management. 6. Neurology consult. 7. Pain management with IV analgesia. 8. Education on symptoms and treatment plan. Signature: Dr. Emily White