DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Migraine headache.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who presents to the ER complaining of persistent headache for the past four days. The patient stated that he was seen by his primary care physician four days ago, and at urgent care this morning, he was given an injection which he claimed has not helped his headache. He was prescribed Phenergan and Fioricet as well.
The patient came to the ER tonight due to continued headache. He stated that he had been sleeping all the time. He denied any fever. No head trauma. No significant neurological symptom. Headache is diffusely over the entire head. He has a history migraine and had a workup in the past with negative CT and MRI. The patient was seen by Neurology in the past as well.
PAST MEDICAL HISTORY: Migraine, otherwise unremarkable.
ALLERGIES: None.
SOCIAL HISTORY: The patient denied any drugs or alcohol abuse. He is single.
REVIEW OF SYSTEMS: As mentioned above in HPI. The patient complained of some photophobia, some nausea. No significant vomiting. No recent illness, fever or any sinus symptoms. Other systems reviewed are negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is a Hispanic male who is sound asleep. This was simply 15 minutes after he was put into the room. When he was awakened, he started complaining of headache immediately.
VITAL SIGNS: Temperature 98.4, pulse 68, respirations 20, and blood pressure 124/70.
HEENT: Pupils are equal and reactive. Conjunctivae are clear. Extraocular movements are intact. Oral mucosa is moist. Posterior pharynx is normal.
NECK: Supple.
HEART: Regular rate and rhythm.
LUNGS: Sounds clear, good bilateral breath sounds.
ABDOMEN: Soft. No tenderness, guarding or rebound.
EXTREMITIES: No joint swelling. Full range of motion actively.
NEUROLOGIC: The patient is awake, alert and oriented x3, no focal deficits.
SKIN: Warm, pink. No rash or lesion.
EMERGENCY DEPARTMENT COURSE: After he was awakened in the ER, he claimed that his headache was bothering him. He complained of photophobia and nausea. He appeared to be somewhat somnolent and drowsy, however. He was given 4 of morphine and 25 mg Phenergan IM in the ER.
DISPOSITION: The patient was discharged home.
IMPRESSION: Migraine headache.
PLAN:
1. Advised to rest.
2. Continue his medication as prescribed.
3. Follow up with primary care physician. Call in a.m.
