DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Headache.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a history of arthritis, hyperlipidemia, and hypertension who presents to the emergency department complaining of a headache that has been worse over the last two days, which she currently does not have at present, but it has been worse over the last two days. She states it seemed to be worse after she fell back in October, almost two months ago. She hit her head and had developed a hematoma but did not have any medical treatment at that time. She did not knock herself out initially and had no associated nausea or vomiting. No weakness, slurred speech, or any other signs and symptoms other than pain. She states that she has had intermittent pain on that side, but the hematoma had resolved, but as this headache had gotten worse over the last two days, over the weekend, she contacted Dr. John Doe’s office today and was recommended to come into the emergency department for further evaluation. She denies any other complaints. No other chest pain or shortness of breath. No new onset of weakness. Just complaining of some right leg difficulty and weakness, which she states is secondary due to her arthritis. She also denies any other complaints. No abdominal pain. No nausea or vomiting. No dizziness. No new weakness. No black or bloody stools, dysuria, or hematuria.
PAST MEDICAL HISTORY: Arthritis, hypertension, and hyperlipidemia.
MEDICATIONS: Blood pressure medications, which she could not remember the name of, and Lipitor.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is married, and her husband is with her today.
REVIEW OF SYSTEMS: As stated in the HPI, all other pertinent review of systems is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, blood pressure is 162/76, pulse 68, respiratory rate 18, and O2 sat is 96% on room air.
GENERAL: The patient is a well-developed, well-nourished Hispanic female who is alert and oriented, in no acute distress.
HEENT: Head is normocephalic and atraumatic. Eyes are PERRLA and EOMI. Oropharynx is clear. Uvula is midline.
NECK: Supple and nontender. No lymphadenopathy present.
HEART: Regular rate and rhythm. Equal S1 and S2. No murmur, rub, or gallop.
ABDOMEN: Soft, nontender, and nondistended. No rebound or guarding.
EXTREMITIES: There is no clubbing, cyanosis, or edema. Distal pulses, radial, DP, and PT pulses are intact and symmetric. Sensation is intact to light touch.
NEUROLOGIC: She is alert and oriented x3. Cranial nerves II through XII are tested and intact. She is moving all four extremities. She is ambulating with a slow but steady gait as she always walks with assistance and did walk without deficit with assistance here in the emergency department and no other deficits appreciated.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient was evaluated and assessed by Dr. John Doe, who agrees with the assessment and plan. After history and physical, nursing notes were reviewed. The patient presented with complaint of a head injury two months ago and had worsening headache over the last two days, which she did not describe as the worst headache of her life, but states that she essentially had not had headaches like this recently. She did state, later throughout her stay, that she did have migraines when she was younger, but she states she had not had migraines in 25 years. She says that this felt similar but is currently now resolved.
DIAGNOSTIC STUDIES: Head CT: The patient had a history of a head injury two months ago. We did elect to go ahead and do a noncontrast CT of her head, which had no acute bleed, infarct, or any other acute abnormality but did show ventriculomegaly out of proportion to the sulci, consistent with NPH, communicating hydrocephalus, remote lacunar, left.
LABORATORY DATA: The patient’s renal panel was within normal limits.
At this time, the patient has had a headache that has resolved; although, she has a remote history of head trauma. There is no obvious bleed or any other acute abnormality. At this time, the patient is agreeable to this plan and will be discharged home
IMPRESSION: Acute cephalgia.
PLAN:
1. Follow up with Dr. Jane Doe as scheduled.
2. Continue home medications as directed.
3. Return for worsening symptoms.
DISPOSITION: Stable, discharged home.
