Headache ER Admission Medical Report Format #1
CHIEF COMPLAINT: Headache.
HISTORY OF PRESENT ILLNESS: This gentleman was involved in a fight and was hit in the head with a steel chair. This happened last Friday, which is 6 days from now. He did go to the emergency room initially. Apparently, he had x-rays done that were negative. He followed up the following day, and the x-rays were done at that time; he states were negative. He has continued swelling and pain.
He has a feeling of pressure behind his eyes, which is most concerning to him. He does not have any visual disturbances however. He has not been nauseated or vomiting. He is coughing up a bit of blood; however, he has no dizziness, no lightheadedness or change in mentation.
PAST MEDICAL HISTORY: Benign. No chronic diseases.
SOCIAL HISTORY: He denies alcohol, tobacco, illicit drug use.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: None.
ALLERGIES: None.
REVIEW OF SYSTEMS: As mentioned. Otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 134/84, pulse 76, respirations 18, temperature 97.4.
GENERAL: He is awake, alert and oriented, in no acute distress.
HEENT: He has some tenderness to palpation in the left periorbital area, specifically in the maxillary area. He still has some bruising of note. He has no tenderness superiorly. He has some tenderness in bilateral temporomandibular joint areas. TMs are intact bilaterally. No evidence of septal hematoma.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. Active bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.
EMERGENCY DEPARTMENT COURSE: He was given 2 Vicodin for the pain while here. Due to a continuance of symptoms, we did do a CT scan of his facial bones with some cuts for the orbital areas. These are still pending at time of dictation.
DISCHARGE DIAGNOSIS: Status post assault with cephalgia.
PLAN: Plan is pending at this time depending on the CT scan.
DISPOSITION: At this time, he remains stable in the emergency room. Final disposition is per the attending.
Headache ER Admission Medical Report Format #2
CHIEF COMPLAINT: Headache.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a headache. It is a dull occipital headache that radiates down his neck. He reports it is consistent with prior migraines. It is not the worst of his life. It was not sudden in onset. He reports it was relieved with ibuprofen. Nothing seems to make it better or worse. He reports some intermittent weight loss recently and some generalized malaise. The patient otherwise has no specific complaints.
PAST MEDICAL HISTORY:
1. Hypertension.
2. High cholesterol.
3. Migraine headaches.
ALLERGIES: Penicillin.
MEDICATIONS: None.
SOCIAL HISTORY: Positive for tobacco, occasional alcohol, no drugs.
REVIEW OF SYSTEMS: CONSTITUTIONAL: Positive for weight loss, no fevers or night sweats. CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GI: No abdominal pain. NEUROLOGIC: No headaches or weakness. MUSCULOSKELETAL: No aches or pains. All other systems are per the history of present illness and are otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 158/86, pulse 62, respiratory rate 16, temperature 98.6 degrees, O2 saturation is 98%.
GENERAL: The patient appeared well and in no distress.
HEENT: Head: No signs of trauma. Pupils are 4-2. TMs are clear. Oropharynx is clear.
NECK: Nontender to palpation.
PULMONARY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2, regular rate and rhythm.
ABDOMEN: Soft, nontender, positive bowel sounds. No rebound or guarding.
NEUROLOGIC: Cranial nerves are intact. Motor is intact. Gait was normal.
EKG, as read by us, showed sinus bradycardia, with a P-R interval of 196, QRS of 90, QTc of 366, normal axis. The patient had ST-wave inversions in leads V4 through V6, as well as II-III and aVF. The patient had LVH by criteria. As compared to a previous EKG, the patient has new T-wave inversions.
RADIOLOGY: Chest x-ray shows a pulmonary nodule. CT of the chest is currently pending.
MEDICAL DECISION MAKING: This is a (XX)-year-old male here with a headache. It is a nonspecific headache, primarily a mild type of headache, probably consistent with migraine. The patient was treated with ibuprofen, with relief of that. It is not the worst headache of his life. He reports he has had neck symptoms and occipital symptoms before in the past. As such, we do not think it is subarachnoid or meningitis. The patient does report some generalized malaise and axillary lymphadenopathy, so he had a chest x-ray done for screening and an EKG done for screening as well.
His EKG shows signs of LVH. He does have some new T waves, without active chest pain or shortness of breath. We do not think he is having an acute MI. The patient does have a chest x-ray that shows a pulmonary nodule. As such, that will be followed up considering he has no good social support and his CAT scan will be done as an emergency room patient. If the patient’s CAT scan shows just a granuloma, the patient will be able to be discharged to home. If shows signs of malignancy, we will arrange further workup at that point.
CLINICAL IMPRESSION: Headache.
DISPOSITION: Discharged to home.
PLAN:
1. Follow up with a regular doctor.
2. Return if symptoms worsen or any concerns.
Headache ER Admission Medical Report Format #3
CHIEF COMPLAINT: Headache.
HISTORY OF PRESENT ILLNESS: The patient complains of a headache in the frontal regions as well as the temporal regions, worse when she bends down. She states she has felt a little off balance. When it gets bad, she has trouble thinking. She has had emesis a couple times since she was prescribed Vicodin. She thinks it is the Vicodin as it is about a half an hour after she takes it for the headache that she has the vomiting. The light does not bother her eyes. She has not had neck stiffness. It is not the worst headache of her life; although, it is a severe one and it was non-thunderclap. She states no sinus drainage.
Nursing notes reviewed.
REVIEW OF SYSTEMS: Negative for any melena, hematochezia, photophobia, neck stiffness, rash, fevers, weight loss, weight gain, difficulty with speech or swallowing, any weakness, any shortness of breath, chest pain, rash, diarrhea. Remainder of review of systems reviewed and negative.
PAST MEDICAL AND SURGICAL HISTORY: Diabetes.
MEDICATIONS:
1. Vicodin.
2. Aleve.
ALLERGIES:
1. Sulfa.
2. Penicillin.
SOCIAL HISTORY: No smoking.
FAMILY HISTORY: Noncontributory.
IMMUNIZATIONS: Noncontributory.
PHYSICAL EXAMINATION:
GENERAL: A well-lit room, does not appear acutely photophobic, resting comfortably.
VITAL SIGNS: Temperature is 97.8, pulse 86, respirations 16, blood pressure is 168/88, room air pulse ox 99%. It is within normal limits.
HEENT: Reveals nonicteric sclerae, PERRLA, EOMI. Oropharynx is clear. Moist mucous membranes. There is noted frontal and maxillary sinus tenderness bilaterally. There is no hemotympanum, no temporal artery tenderness, no meningismus.
MENTAL STATUS: Alert and oriented x3.
CHEST WALL: Nontender.
HEART: Regular rate and rhythm without murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly.
EXTREMITIES: No clubbing, cyanosis, edema.
SKIN: No rash, good turgor, warm and dry.
NEUROLOGIC: Cranial nerves II-XII intact without motor, sensory or cerebellar deficits. Reflexes 1+ and equal.
LABORATORY DATA: Electrolytes reveal the following abnormalities: Glucose 312, sodium 129, chloride of 92, has a normal potassium and CO2. Urinalysis shows glucosuria, ketonuria, trace protein, small blood, trace leukocyte esterase.
CT SCAN: A CAT scan of the head interpreted by the radiologist shows atrophy, no acute abnormality.
ADDITIONAL DATA: None.
EMERGENCY DEPARTMENT COURSE: Given inapsine here with symptomatic relief.
PROCEDURE: None.
CRITICAL CARE: None.
CONSULTATIONS: None.
MEDICAL DECISION MAKING: We do not feel we are dealing with entities to include, but not limited to, encephalitis, meningitis, intracranial bleed, temporal arteritis. We think we are dealing with acute sinusitis. The patient has been told that the only way to rule out a bleed is with a LP. This is something she does not want to have done. She understands and agrees the risks and benefits of her decision. Personally, we do not think it is something that is entirely necessary as the patient has been having these symptoms for 2 weeks. She has no meningismus symptoms over that period of time. We think she is dealing with a sinusitis. The vomiting may be secondary, not to an intracranial problem, but to intolerance to Vicodin so we will place her on Fioricet.
IMPRESSION:
1. Cephalgia.
2. Acute sinusitis.
PLAN:
1. Follow up with Dr. John Doe in 2 days.
2. Return to the ED if neck stiffness, photophobia, fever, trouble with speech or worse in any way.
3. Stop Vicodin.
4. Prescription for Fioricet and Z-Pak is given.
Headache ER Admission Medical Report Format #4
CHIEF COMPLAINT: Headache.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female, who is otherwise healthy, who presented to the ED with complaints of a 6-week history of diffuse headache and neck pain that has been constant. She states it is a constant aching pain, rates it as 7/10 in severity, worsened when she bends over and associated phonophobia.
She denies any change in her pain at different times of the day. It is not particularly worsened in the morning. Not thunderclap in its onset. She reports subjective fever and chills with nausea, no vomiting, has had no relief with ibuprofen at home as well as a migraine medication that her doctor prescribed for her.
She is currently rating her pain as 7/10 in severity. It does not radiate. She denies visual changes, dizziness or lightheadedness. The patient states that over the course of the last 6 weeks, she has seen her eye doctor and had a prescription change. This was approximately 1 month ago and has not noticed any change with this or with changing her monitor at work.
She had an MRI done yesterday as an outpatient by her primary care physician and also had blood work drawn at that time and was told she had elevated monocytes, was told that the MRI results were fine. She denies paresthesias, numbness, coldness, loss of range of motion or weakness in the extremities and otherwise has no complaints.
PAST MEDICAL HISTORY: Bladder sling approximately 3 years ago.
MEDICATIONS: None.
ALLERGIES: Multiple drug allergies listed in note.
FAMILY HISTORY: Breast cancer, coronary artery disease, and Hodgkin lymphoma.
SOCIAL HISTORY: She denies tobacco, alcohol or illicit drug abuse. Dr. Jane Doe is her primary care physician.
REVIEW OF SYSTEMS: As stated above in the HPI significant for diffuse headache, associated neck pain, subjective fevers, chills, and nausea as well as phonophobia. She denies dizziness, lightheadedness, visual changes, chest pain, shortness of breath, polyuria, polydipsia, heat or cold intolerance, fatigue, recent weight changes, rashes or lesions. Further review is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 108/72, pulse 70, respirations 18, temperature 99.0, and pulse ox on room air is 98%.
GENERAL: This is a well-developed, well-nourished female in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles intact. Mucous membranes are pink and moist. There is no tenderness with palpation over the temporal arteries.
NECK: Supple. There is no nuchal rigidity or meningismus.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, nondistended, nontender. Bowel sounds normoactive in all 4 quadrants. There are no masses or hepatosplenomegaly appreciated.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Warm, dry and intact.
NEUROLOGIC: Cranial nerves II through XII are tested and intact. She has good finger-to-nose-to-finger, rapid hand movement, and heel-to-shin movement. She has full 5/5 strength with resisted movement in all muscle groups of the upper and lower extremities bilaterally. Sensation is intact to light touch. There are no focal neurologic deficits.
EMERGENCY DEPARTMENT COURSE: The patient had IV access established. She was given 1 liter of normal saline, Toradol 30 mg IV, and Compazine 10 mg IV after which she reported significant improvement in her pain, rating her pain as a 2/10 in severity.
LABORATORY STUDIES: Include CBC with white blood cell count of 5.0, hemoglobin 13.2, hematocrit 39.4, and platelets 275. Sed rate is normal at 5.
EMERGENCY DEPARTMENT COURSE: MRI results were obtained from outside hospital. The impressions read as follows: No aneurysm is seen; however, is only sensitive in detecting aneurysm 3 mm larger. This examination is also limited by motion artifact. Irregularity of the internal carotid artery is present bilaterally. This is likely secondary to motion, but for confirmation of this, a CT angiogram could be done for better evaluation if clinically needed. A few scattered foci of increased FLAIR signal seen in the subcortical white matter. This is a nonspecific finding. Small foci of gliosis from prior trauma or prior infection can have a similar appearance. Migraines can cause similar abnormal lesions. They are not in a classic location for demyelinating disease. Sequelae of small vessel ischemic disease would be unusual given the patient’s young age unless a secondary diagnosis of diabetes or hypertension is present. No intracranial hemorrhage, mass or acute infarct. Dr. John Doe saw the patient and agreed with the assessment and plan.
DIAGNOSIS: Cephalgia.
PLAN:
1. She is given a prescription for Fioricet to take as directed for pain. She is told not to drive with this. She should also take Advil or Motrin as needed for pain as well.
2. Follow up with her primary care physician if there is no improvement in the next 2 to 3 days.
3. Return to the ED for vomiting or other worsening symptoms.
4. Increase her fluid intake.
DISPOSITION: She was discharged home in good condition and ambulated out of the department without difficulty.
