- @ GENERAL REPORT ccAM | PRIVACY ACT MATERIAL REMOVED STRAUB CLINIC & HOSPITAL, INC. Honowutu, nawan ‘ oo DATE OF ADMISSION: DATE OF DISCHARGE: 054650-2 | | a - INDICATE NAME OF REPORT am“ l DISCHARGE SUMMARY March 19, 1982 April 14, 1982 FINAL PRIMARY DIAGNOSIS: MENINGIOMA ~ FINAL SECONARY DIAGNOSIS: PNEUMONIA HISTORY OF PRESENT ILLNESS: This is the first. Straub Hospital admission for this 43year-old woman who is a former resident of the Marshall Islands. She reported a febrile illness 3 weeks prior to admission which was followed by bitemporal to generalized throbbing type headache which was progressive and present 24 hours a day unrelieved by aspirin or Tylenol. She also described attacks of hearing noise in her ears followed by dizziness. Her neck had become progressively stiffer and more painful. She described bracing herself against a wall so that her neck would be supported. She has no family history of neurologic disease. ® PAST MEDICAL HISTORY: She had had a hysterectomy 10 years prior to admission. other serious illnesses or accidents or infections. No REVIEW OF SYSTEMS: Negative in detail. She denies allergies. She takes Tylenol as needed for pain. There have been no-psychtatric, G.I., G.U.,endocrine, pulmonary, tardiac.or skin problems. She smokes: about 1 pack of cigarettes a day. She uses occasional alcohol. r ’ PHYSICAL EXAMINATION: She was an 131-appearing woman. BP 140/90, heart rate 62; temperature 37. HEENT: Negative for injury otherwise unremarkable. Neck was held: stiffly. Oropharynx benign. Thryoid not palpable. Lungs were clear. Breasts without masses or discharge. fReart was regular without significant murmur, rub or gallop. Abdomen-was nontender. No organomegaly. Extremities were without edema.- Rectal and pelvic exams were not done. @ Neurologic exam showed a somewhat lethargic:woman with’no decrease in mental status. She appeared to neglect the left side.on occasion. Cranial nerves: I) She smelled wintergreen. II) Visual fields were full to confrontation, fundi showed no papilledema. III, IV and VI) Pupils were 4 mm, reactive to light. V) Corneal response is symmetric. VIE) No facial weakness. VII-XII) Appear normal. Motor examination showed no definite hemiparesis. Reflexes were 1-2 throughout.- Patient had questionable bilateral Babinsk4 responses. of tenderness. Sensory and cerebellar exams were normal. The spine‘had no areas Lumbar ‘puncture yielded opening pressure of 210, closing pressure of 180. Total protein was 103, glucose 65. .-In tube #1, there were 4 white cells and in tube“#4:there were 4 white cells. In.tube-#1 there were 38 red cells:and in tube #4.there were 117 red cells. esion. Differential count showed mostly lymphocytes. . CT scan showed right hemispheric The patient.was: admitted to-the hospital and treated with steroids and Manito] with improvement in her symptomatology. 3 Evaluation subsequently included normal SMA-12' except for elevation in LDH, normal 2 electrolytes. | (CONTINUED) CBC ‘showed hematocrit of 37.2, white count of 9.1. FORM 021518-6 REV 3/79 ro SOG 733 5 . ‘ 37 , . Normal urinalysis. Be PRIVACY ACT MATERIAL REMOVED