病历_3_20_63
{"patientName":"Calvin Corsemi","Outpatient Medical Record":"Basic Information:\nPatient Name: Calvin Corsemi\nDate of Visit: [Insert Date]\nAge: [Insert Age]\nSex: Male\nDate of Birth: [Insert DOB]\nPrimary Care Physician: [Insert Physician Name]\nChief Complaint:\nSevere headache, possible migraine, with associated neck stiffness and head pressure when moving eyes or head.\nHistory of Present Illness:\nThe patient has experienced severe headaches for the past three days, described as a migraine, along with neck stiffness. The patient also reports feeling head pressure when moving their eyes or head. The patient took Excedrin and felt better. There was a fever for three days, reaching over 100°F, which resolved yesterday morning. The patient mentioned light coughing today and, occasionally, muscle aches localized to the neck region.\nPast Medical History:\nRecent gallbladder removal by Dr. Kim.\nNo history of migraines or serious illnesses noted.\nPatient has been in a gap year after school.\nPersonal and Family History:\nThe father, Carlo, mentioned no respiratory illness history but experienced similar symptoms, including hand stiffness especially in the morning, suggestive of early signs of arthritis. The father has not had a flu vaccine.\nPhysical Examination:\nEyes: No signs of meningeal irritation detected.\nNeck: No stiffness or pain upon movement.\nChest and Lungs: Clear to auscultation bilaterally.\nNeurological: Cranial nerves II-XII grossly intact.\nExtremities: No swelling, hands examined for signs of arthritis.\nAuxiliary Tests:\nNone indicated at this time.\nDiagnosis and Assessment:\n1. Headache, likely viral in etiology.\n2. Neck stiffness, possibly related to viral infection.\n3. Intermittent fever, resolved.\n4. Light cough, monitored.\n5. Patient's father likely presenting with early signs of arthritis.\nTreatment Plan:\n1. Headache management with acetaminophen or continued use of Excedrin. \n2. Adequate hydration and rest.\n3. No antibiotics required as this appears to be a viral infection.\n4. Monitoring symptoms; seek further evaluation if symptoms persist or worsen.\n5. Flu vaccine to be administered to the father; recommended for Calvin as well.\nFollow-Up Care:\nSuggested follow-up appointment if the headaches and other symptoms persist, and to assess the need for further interventions. Recommends keeping a watch for early signs of arthritis in the father."}