ID Case Conference 11-28-07. Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases. CC: neck pain.
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ID Case Conference 11-28-07
Gretchen Shaughnessy, MD
Dept of Infectious Diseases
Afebrile – P 74, R 18, BP 134/75, 97% on RA
INAD, wearing c-collar
EOMI, PERRLA, nonicteric
No e/e on OP
No LAD appreciated in cervical, supraclavicular, axillary, or inguinal regions
RRR no murmurs
No rashes or skin lesions, no nail lesions
A&Ox3, pleasant and cooperative, talkative.
Soft NT NABS
No c/c/e, pulses 2+ and equal in BU and LE
Normal tone, full ROM present. No tenderness to palpation of thoracic or lumbar spine. No apparent tenderness to palpation when I watched neurosurgery palpate the patient’s cervical spine.
CN II-XII intact, strength 5/5 in BU and LE, reflexes 2+ in BU and LE, cerebellar exam intact
Uric Acid 5.0
Alk Phos 110