Correct!
4. Obtain additional history and a more thorough physical examination
Cultures may eventually provide a diagnosis and were obtained. However, they will not give a diagnosis at this time. CT scans of the chest, abdomen and pelvis were also obtained by the ER physicians and were interpreted as normal. The lack of symptoms or signs pointing to pathology in these areas makes CT scanning a low yield test. Bronchoscopy with bronchoalveolar lavage is not indicated and very unlikely to provide a diagnosis in a patient who has no thoracic symptoms, a normal chest x-ray and a normal CT scan.
After consideration, we decided that we didn’t have a tenable diagnosis and must be missing something. We took more history. The only recent travel history outside Arizona was a sailing trip in San Diego two months previously. The patient reported no history of camping, hunting, tick bites (although his wife interjected that “mosquitoes love him”), no exposure to animals except his pet cat, no cat bites or scratches, no ingestion of unpasteurized diary products (such as Mexican cheese) and no recent exposure to anyone else who was ill. Recalling his possible confusion when previously asked about headaches, he was asked again. He reported that he had been having severe headaches and photophobia for the past four days. His wife stated that she had wondered why he had originally denied headaches since he had been asking her for ice-packs for his head for the past three days. A more thorough physical examination was repeated and there no additional findings discovered including nuchal rigidity (stiff neck) and no focal neurologic signs.
Which of the following is (are) the best next step(s) in management of the patient?