Age: 27.0
Sex: M
Vaccine: ANTH, FLU3, HEP
Symptoms: Headache, Lumbar puncture normal, Malaise, Musculoskeletal discomfort, Musculoskeletal stiffness
Clinical narrative: History of present illness   The Patient is a 27 year old male.   He reported: Encounter Background Information: Patient seen today for evaluation of headache which began last night with associated cold sweats. He has chills associated. He has pain over the top of his head. some nausea with inability to eat he has been drinking fluids. He has not taken any medication for this. No URI symptoms. He has pain in the back of his neck. He had vaccines yesterday afternoon. Has had recurrent headache behind left eye for the past few months intermittently without medical evaluation or treatment. Today he reports that the headach is different.  Head symptoms As above.  Neck symptoms. Past medical/surgical history  Reported History: Past medical history No chronic disorders, no allergies, no regular medications. Personal history  Social history Smokes 5 cigarettes a day. Review of systems  Eye symptoms: No eye symptoms. Otolaryngeal symptoms: No otolaryngeal symptoms. Cardiovascular symptoms: No cardiovascular symptoms. Pulmonary symptoms: No pulmonary symptoms. Skin symptoms: No skin symptoms. Physical findings  Vital signs: Normal. General appearance: General appearance: Patient appears awake and oriented but with severe headache and neck stiffness holding his head. Neck: Neck: Stiffness and tender with ROM. Eyes: General/bilateral: Eyes: normal. Ears, Nose, Throat: ENT: normal. Lungs: Normal. Skin: Normal.    1. headache: Patient has associated nausea and neck discomfort with reported fever last evening after receiving vaccines yesterday. We will refer him via ambulance to ER for further evaluation and management.  F/U on 04Oct2010 Chief complaint  The Chief Complaint is: Patient had anthrax vaccine a week ago.  Felt sick the next day and with question of spinal meningitis sent to Hospital.  Dx with reaction from the shot.  Had neg spinal tap.  Was on quaters x two days and last Friday placed on light indoor duty over the week end.  Has been having headaches since after the spinal tap.  Pain temporal, frontal and behind both eyes.  Pain described as throbbing and also as sharp.  Pain rated 6/10 now and rated up to 8/10.  Worse with activity.  Better with vicodin however vicodin doesn't get rid of it.  No improvement of headache since after the spinal tap. History of present illness   The Patient is a 27 year old male.   HPI [use for free text]. Allergies  Allergy information in Autocite area was reviewed and verified with patient. . Current medication  current medication [Use for free text]. Past medical/surgical history  Reported History: Reported medications: Medication history including current prescription medications; over-the-counter medications; nutraceuticals; herbals; supplements and medications not included in AHLTA were reviewed with patient in detail. . Review of systems  ROS is positive for the following:  NEURO:  See HPI Otherwise all remaining systems are negative. . Physical findings  Gen: BP/HR/Temp reviewed; A/Ox3; NAD Eyes: PERRLA; Conjunctiva normal.  Neck: Supple; No thyromegaly Cranial Nerves:  Cranial nerves II-XII intact.  Head:  Patient is tender over the fromtal and temporal areas and with pain behind the eyes.      Rads No Rads Found.    1. HEADACHE SYNDROMES: Refer to neurology for evaluation / tx.  Quastion of spinal fluid leak post lumbar puncture.  Medication(s):   -HYDROcodone/APAP--PO 5MG/500MG TAB [PENDING PDTS] - T 1-2 TB PO Q6H PP #15 RF0 Qt: 15 Rf: 0     Released w/ Work/Duty Limitations  Follow up: as needed with PCM. - Comments: refer to neurology for evaluation / tx.  Consider spinal fluid leak / need for patch.   Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding. - Comments: 20 min face to face spent coordinating care.  20 minutes face-to-face/floor time. >50% of appointment time spent counseling and/or coordinating care.