ED SOAP Note
Name: Jane Doe
DOB: xx-xx-1975
Date: 10/10/2012
Subjective:
CC: Headache x 3 days
HPI: 37 yo female presents to ED with headache x 3 days. Patient reports headache in frontal
region, started 3 days ago, constant in nature with gradual increase in pain, progressive in degree
of pain, no radiating pain into neck, posterior or temporal areas of head, described as “pressure”
pain. No alleviating factors noted by patient. Alternating doses of Tylenol and Advil have not
relieved headache. Headache present throughout the day and continues into the evening hours.
Does not wake her from sleep. 7/10 in pain severity. Associated symptoms of nausea, 2 episodes
of vomiting, photophobia. Denies fever, dizziness, syncope, visual changes or ocular pain,
auditory changes, recent illness or head trauma, back pain, diarrhea, constipation. Patient states
she has history of migraines, with similar symptoms as on presentation, but has not had one in 2
years. Patient denies having CT scan in the past.
Meds: No daily medications.
1.
Tylenol 500 mg 2 TAB PO q8H PRN for pain.
2.
Advil 200 mg 2 TAB PO q6-8H PRN for pain.
Allergies: Kelfex – breaks out in hives, Darvocet – breaks out in hives.
ROS:
General: Denies fever, chills, weakness, fatigue, weight loss/gain, night sweats.
HEENT:
Head – Reports headache. Denies head trauma, lesion or contusion.
Eyes – Reports photophobia, wears corrective lenses for myopia. Denies change in
vision, diplopia, tearing, blurriness.
Ears – Denies auditory changes, tinnitus, vertigo, otalgia.
Nose – Denies epistaxis, nasal congestion, sneezing, rhinorrhea.
Mouth/Throat- Denies pharyngitis, dysphonia, dysphagia.
Neck: Denies swollen neck, history of thyroid disease.
Resp: Denies SOB, coughing, history of TB or pneumonia, asthma. Last CXR unknown.
Cardiac: Denies HTN, heart murmur or arrthmia, DOE, edema. Last EKG 10/05/2012.
GI : Reports nausea, 2 episodes of vomiting, 1 BM/day. Denies abdominal pain, change in stool
color/consistency, diarrhea, constipation, GERD.
GU: Denies urinary frequency/hesitancy/urgency, change in urine color/odor, dysuria.
Vasc: Denies edema, varicose veins, history of DVT or PE.
Muscl: Reports full ROM intact. Denies muscle weakness, myalgia, instability.
Neuro: Reports history of migraine headaches. Denies LOC, fainting, seizures, numbness,
tingling.
Endocrine: Denies polyphagia/polyuria/polydipsia, hyperhydrosis, intolerance to heat/cold.
Psych: Denies history of depression, anxiety, change in memory.
PMH: Migraines, SLE. Denies HTN, HLD, MI, CAD, CVA, seizures, DM.
Family Hx: Mother and father still alive. Father has HTN, HLD. No known maternal medical
conditions. Denies family history of MI, CAD, CVA, seizures, DM.
Social Hx: Smokes ½ ppd. Approximate pack years: ½ ppd x 10 years = 50 years. Denies alcohol
or illicit drug use.
Objective:
Physical Examination
General: NAD, well-nourished, well-developed 37 yo female.
VS: Ht. 60 in., Wt 175 lbs., BMI 34.2, T 98.6 F, BP 132/70, P 108, RR 16, SaO2 99% on room
air
HEENT
Head: Normocephalic. No signs of head trauma, abrasions, lacerations, contusions.
Eyes: White sclera. No conjunctival injection or subconjunctival hemorrhage. PERRLA
and EOMI. Direct and consensual ocular reflexes intact. Fundoscopic exam revealed 1:2 cup to
disc ratio and 4 arcades noted bilaterally. No retinal edema, hemorrahages, cotton wool patches
or AV nicking noted. Fundoscopic exam limited by pupil restriction to light and patient
discomfort.
Ears: Pearly gray TMs identified bilaterally, mild cerumen present in left ear. No signs of
trauma to auricles or external auditory canals bilaterally. Non-tender tragus bilaterally. No
discharge in external canal or behind membrane, bulging or ruptured membrane, fluid or
hemotympantum noted behind TM B/L.
Nose: Patent nares bilaterally, pink turbinates, clear nasal discharge, nasal septum
midline. No blood noted.
Throat: Uvula midline, equally rises and falls. MMM, non-erythematous or edematous
pharynx, no exudates or post nasal drainage noted on inspection.
Neck: No carotid bruits identified on auscultation. Supple, non-tender neck. Thyroid equally
rises and falls. No asymmetry or nodules noted on palpation. No meningeal signs – negative
Brudzinski reflex or Kernig’s signs.
Lymph: No palpable lymphadenopathy in pre/post auricular, occipital, anterior/posterior cervical
chain, tonsillar, submental, submandibular areas, supraclavicular, infraclavicular or axillary
areas.
Resp: AP/Lateral chest ratio 2:1, lungs symmetrically rise and fall. No asymmetry or deformities
of chest wall, accessory muscle use. Resonant sounds throughout lung fields on percussion B/L,
CTA B/L. No wheezes, rhonchi, or rales appreciated on auscultation.
Cardiac: RRR, S1 and S2 identified, no M/G/R, S3 or S4 appreciated on auscultation. No
obvious lifts or heaves noted on inspection, no palpable lifts, heaves or thrills. PMI not
identifiable on inspection.
GI: Symmetric, mildly obese abdomen. Active bowel sounds noted x4 quadrants. No
abdominal/femoral bruits appreciated on auscultation. Tympanic abdomen with percussion in 4
quadrants. No ascites. Palpable liver 6.5 cm right MCL. No palpable spleen, masses,
organomegaly with light/deep palpation. NTND.
Extremities: No deformities or edema noted. Gross ROM intact.
Vasc: Distal pulses +2/+2 radial, +2/+2 dorsal pedal pulses +2/+2.
Skin: Warm, moist skin. No cyanosis or rash.
Neuro: AAOx3.
Cranial Nerves
CN1 – not assessed on exam
CN2 – Visual acuity 20/20 bilaterally with corrective lenses.
CN3,4,6 – EOMI, PEERLA.
CN5 – sharp vs. dull distinction intact in ophthalmic, maxillary and mandibular
regions.
CN7 – Patient able to smile, frown, keep eyelids closed against resistance.
CN8- Hearing grossly intact, assessed through appropriate responses in
conversation.
CN9- Swallowing intact
CN10- Uvula midline, equally rises and falls. No lateral deviation.
CN11- Shoulder shrug intact
CN12- Tongue midline, moves against resistance. No lateral deviation.
Sensory - Dermatomes randomly sampled from fingertips to shoulders and facial area
intact to light touch sensation B/L. Sharp vs. dull distinction intact from fingertips to shoulders
and facial area. Vibratory sensation in UE/LEs intact. Two point discrimination, graphesthesia,
stereognosis.
Motor - Voluntary movement intact on inspection, symmetrical muscle mass in
upper/lower extremities. No cogwheeling or stiffness with passive ROM in upper/lower
extremities.
Strength (AROM against resistance):
Muscle group
Left
Biceps
+5
Triceps
+5
Forearm flexors
+5
Forearm extensors
+5
Grip
+5
Shoulder add/abductors
+5
Quads
+5
Hamstrings
+5
EHL
+5
Plantar flexors
+5
LE add/abductors
+5
Right
+5
+5
+5
+5
+5
+5
+5
+5
+5
+5
+5
Reflexes:
Reflexes
Triceps
Biceps
Brachioradialis
Patellar
Left
+2
+2
+2
+1
Right
+2
+2
+2
+2
Achilles
+2
+1
Cerebellar – Rapid tongue movements intact, finger-to-nose intact B/L, heel slides intact
B/L, heel to toe walking intact. No loss of balance when standing in Rhomberg position.
Negative pronator drift.
ED Course Order:
1. Labs –
a. CBC
b. CMP
c. UA
d. Values within range on CBC and CMP. No glucose, ketones, RBCs found in
urine.
2. Head CT
a. Report – no acute intracranial process.
3. Fluids/Medications to be given:
a. Saline lock.
b. IV NSS 125 mg/hr.
c. 10 mg Reglan IV immediately in ED at 1335
i. Side effects of Reglan – drowsiness, restlessness, fatigue, extrapyrimidal
effects, dizziness.
d. 30 mg Toradol IV immediately in ED at 1335
i. Side effects of Toradol – headache, abdominal pain, nausea, dyspepsia.
ii. Confirmed with patient that she had no history of ulcers which could be
made worse with Toradol.
e. 25 mg Benadryl PO immediately in ED at 1335
i. Side effects of Benadryl - allergic reaction, drowsiness, dizziness,
headache, dry mucus membranes.
f. Addendum to orders: 1 mg Diluadid IV
i. Patient did not have pain relief with Reglan, Benadryl and Toradol.
ii. Dilaudid given for pain relief.
1. Side effects of Dilaudid – nausea, vomiting, constipation,
dizziness, drowsiness.
2. Patient educated on risk of rebound headache after Dilaudid wears
off.
Assessment:
Diagnosis: Migraine headache
DDx: Migraine headache, tension headache, sinusitis, subarachnoid hemorrhage, epidural
hematoma
1.
Migraine headache – Her PMH supports the possibility of a recurrence of migraine
headaches. Migraine headaches present with throbbing unilateral pain, nausea, vomiting,
photosensitivity. Patient presented with many of these symptoms including nausea, vomiting and
photosensitivity as well as a history of similar migraine pain in the past. These symptoms support
the diagnosis of migraine headache.
2.
Tension headache – This type of headache are associated with emotional stressors. On
exam, tenderness may be noted over frontal region. Patient did not note any tenderness on exam,
nor did she express any recent stressor in her life which would have caused the sudden increase
in headache.
3.
Sinusitis – Patients usually present with frontal headache, fever, nasal congestion, coughing
and other signs of acute inflammation and irritation in facial region. The patient did not have any
nasal congestion or post-nasal drip, cough or tenderness of frontal or maxillary regions on
physical exam when noting sensation. Because there was no congestion noted on physical exam
or tenderness, sinusitis was not the most probable diagnosis based on clinical findings.
4.
Subarachnoid hemorrhage – This condition presents with head pain referred to as a
“thunderclap” headache which comes on suddenly as the “worst headache.” On exam, there may
be nuchal rigidity noted. The patient stated that her headache had insidious onset and gradually
worsened over last 3 days. No nuchal rigidity was noted on physical exam, patient was able to
shrug shoulders and turn head bilaterally without discomfort. Although the CT exam was
negative for brain bleeding, subarachnoid hemorrhage could still be present. The confirmative
test would be lumbar puncture. This was deferred at this time because the patient was not
presenting with the clinical symptoms of thunderclap headache or nuchal rigidity. It symptoms
worsen, lumbar puncture would be performed.
5.
Epidural hematoma – this diagnosis usually presents after head trauma with LOC. There
also may be associated symptoms of nausea, vomiting, headache and pupil dilation. Patient was
nauseated and had been vomiting, but she did not have any recent head trauma and her pupils
were equal and reactive to light. Because her clinical presentation did not have either head
trauma or pupil changes, epidural hematoma was low on the differential.
Plan:
1.
2.
3.
Medications
a. Patient given following prescriptions at discharge from ED:
i. Zofran 4 mg PO QID PRN for nausea
1. Side effects- headache, fatigue, constipation, diarrhea, dizziness.
ii. Toradol 10 mg PO Q4-6H PRN pain
1. Side effects – nausea, abdominal pain, dizziness, headache,
constipation, flatulence.
Patient education
a. Patient recommended to continue alternating Tylenol and Advil PRN along with
Toradol until follow up with family physician.
b. Patient to avoid bright lights, loud sounds until headache resolves.
c. Smoking cessation – patient educated on smoking cessation. Patient educated on
the different modalities to use to stop smoking: Nicotine patches, nicotine gym,
Chantix tablets, electric cigarettes, “cold turkey” method.
Follow up
a. Patient advised to contact family physician, Dr. Kreider, tomorrow to schedule
appointment to further address migraine headaches.
b. Patient to return to ED if headache worsens, nausea and vomiting return or if
additional symptoms occur.
Alyson Wattai, PA-S