Name: Lena D.
MRN: 123456
DOB: 4/14/1984
Age: 28
CC: Severe headache last night
Subjective:
Pt is a 28 year old female, G1P0000, who presents to the ED after experiencing a severe headache with
some “flashing lights” in her right eye last night while traveling in the area with her husband to visit
family. Upon calling her OB-GYN in Butler, Mrs. D was told to visit the ED for further evaluation for
possible pre-eclampsia. Pt is 24 weeks pregnant, her LMP was 6/09/12 and her estimated date of
delivery is 3/17/12. She states that this is the first time she has experienced a headache like this, with
the pain being a 7/10 at its worst. Her headache was primarily located in the frontal area, with some
radiation to the temporal areas bilaterally. Pt states that she was helping cook dinner when the
headache started and that she laid down as the pain increased, with the headache going away after
about 4 hours. Pt states that the “flashing lights” in her right eye lasted for about 20 minutes and then
went away. She is currently has no headache and her vision is back to normal. Pt denies trauma to the
head, loss of consciousness, dizziness, history of hypertension, blurry vision, RUQ pain, nausea, vomiting
or changes in bowel habits. She also denies any vaginal discharge or leaking, bleeding or pain.
Today Pt states that she has no headache and is in the ED “just to make sure everything is alright”. She
is scheduled for a routine pre-natal visit in Butler with her OB-GYN in two weeks.
Family Hx: Past family history is significant for DM in her mother and a history of stroke in both of her
grandfathers. Denies family history of hypertension, pre-eclampsia, eclampsia, gestational diabetes,
blood/clotting disorders and cardiovascular disease.
Social Hx: Pt is a dental hygienist and lives in Butler with her husband. Pt denies ever using tobacco
products and has never used illicit substances. Pt states that she used to drink socially, but has not
consumed any alcohol since February.
Allergies: Penicillin (skin rash)
Immunizations: Current
Medications: OTC Pre-natal vitamin daily
0.4mg Folic Acid daily
PMH: None
PSH: Appendectomy (2000)
Objective:
Vitals: Temp: 97.3F HR: 76 RR: 20 BP: 116/68 Weight: 153 lbs. Height: 65 inches BMI: 25.5
Fetal HR: 150s
General: Pleasant, well groomed, resting quietly on exam table; A&O x3; No acute distress, well
nourished
Head: Normocephalic, atraumatic; No contusions, lesions or tenderness
Eyes: PERRLA; Conjunctiva and sclera clear; EOM intact; No ptosis or nystagmus; Fundoscopic exam
reveals cup-to-disc ratio of 1:3 with no papilledema
Nose: Nostrils patent bilaterally; No erythema or nasal discharge; Non-edematous with no polyps or
lesions
Mouth: Moist mucous membranes; No erythema of oropharynx or tonsils; Dentation in good repair with
no caries noted; Gums non-erythematous; No lesions, masses or ulcers
Neck: Supple, trachea midline; No carotid bruits, no thyromegaly, and no lymphadenopathy of occipital,
posterior/anterior cervical chains
Breasts: Non-tender; No nipple inversion, discharge or asymmetry; No masses or lesions; No
supraclavicular or axillary lymphadenopathy.
Chest: Non-labored breathing, no accessory muscle use or intercostal retractions; No scars, ecchymosis,
asymmetry of chest; Lungs CTA bilaterally, no wheezing/rales/rhonchi/stridor
Heart: R/R/R; No murmur/rubs/gallops
Skin: Warm, pink, dry; No pallor, cyanosis, rashes or bleeding
Abdomen: Pregnant abdomen with minimal striae; No scars, lesions or masses; Non-tender, fundal
height 21cm; Uterus soft
Pelvic – Not performed; If indicated, I would evaluate the external genitalia for adhesions or lesions,
look for blood or discharge in vagina. I would also evaluate the cervix for color and patency of the os.
Extremities: Minimal edema limited to the foot/ankle regions bilaterally; No calf tenderness bilaterally
Labs/Tests:
UA: negative for WBCs, protein, blood, and glucose
CBC: Hemoglobin
Hematocrit
12.2
34.8
Blood Type: B+
Assessment:
1) Migraine Headache with aura
2) Single Intrauterine Pregnancy, 24 weeks without complications
Differential Diagnosis: Tension Headache
Plan:
1) Migraine Headache: Based on Mrs. D’s negative UA, normal blood pressure and
unremarkable blood work, the possibility of pre-eclampsia is diminished. Discussed with
patient the likelihood of this being either a tension headache or migraine headache. Pt has
no history of migraine headaches, but if she has additional headaches of a similar, she was
encouraged to seek further evaluation. Hard copies of today’s labs were given to the
patient to take with her to her next OB visit in two weeks.
2) Single Intrauterine Pregnancy: Pt’s prenatal care is up-to-date and she is scheduled for her
next routine visit in two weeks. Instructed Pt to continue taking her pre-natal vitamin and
folic acid supplement as prescribed. Also encouraged Lena to continue eating a healthy diet
with fruits, vegetables, lean protein and lots of water.
Additionally, if Mrs. D’s symptoms return or worsen or if she experiences any vaginal leaking/discharge,
pre-term labor, or bleeding, she was instructed to contact her OB-GYN and return to the ED. Pt agrees
to plan and will return to the ED if needed.
Vanessa G Wittstruck, PA-S
11/26/12
14:34