H&P

History

Identifying Data:

Full Name: O.D.

Address: N/A

Date of Birth: N/A

Date & Time: 2/14/2023, 1: 00 pm

Location: Queens Presbyterian Hospital 

Religion: N/A

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: N/A

Chief Complaint: “I’m here because I have a really bad headache that started this morning.”

History of Present Illness:

37 year old female with PMH of HLD, recurrent headaches, presenting for typical headache since this morning at 6am. Patient states headache began at left retrobulbar area and radiated to occiput She describes the pain as pressure like and headache is associated with photo- and phono-phobia and improves slightly with Tylenol. Patient also notes headaches have been lasting longer for 8-9 hours. Notes she recently was cleaning and moving furniture around and bumped her head on bed frame. However, she denies any significant trauma, loss of consciousness, numbness, weakness, tingling, fever, rash, nausea, or chills. LMP was 01/27/23 and not on OCPs. 

Initial DDx:

• Migraine w/o aura
  • Patient’s symptoms fit clinical picture of a migraine. She has a unilateral headache with photo- and phonophobia.
• Cluster headache
  • She has a unilateral headache, but no other associated symptoms such as runny nose, lacrimation, or ipsilateral conjunctival injection. Cluster headaches are also more common in men, but no impossible to occur in women.
• Subarachnoid hemorrhage
  • Subarachnoid hemorrhage can present as a sudden “thunderclap” headache. The patient also had recent head trauma, although it wasn’t significant and didn’t result in loss of consciousness.
• Stroke
  • Symptoms of stroke can sometimes be mistaken for a migraine. However, the patient’s neurological exam was unremarkable.
• Acute Angle Closure Glaucoma
  • It can cause eye pain and headache which the patient complained of but she had no associated vision loss and pupils were equal, round, and reactive to light.

Past Medical History:

Hyperlipidemia x 5 year, not on any medications

Childhood Illnesses- N/A

Immunizations – Up to date; flu vaccine yearly, COVID vaccine (most recent June. 2022)

Screening test and results – N/A

Past Surgical History:

No past surgical history.

Denies any blood transfusions.

Medications:

Not on any medications.

Denies use of herbal supplements.

Allergies:

NKDA

Family History:

Mother – Alive and well

Dad – Alive and well

Children – Alive and well

Maternal/paternal grandparents – Deceased at unknown age & unknown reasons 

Family history of cancer. Denies family h/o diabetes and myocardial infarctions.

Social History:

Mr. O.D. is married. Lives with her husband.

Habits – Denies tobacco use. No history of alcohol abuse, denies history of illicit substances. Drinks 1cup of coffee a day.

Travel – No recent travel.

Diet – She states he has a well-balanced diet.

Exercise – Does not exercise.

Safety measures – Admits to wearing a seatbelt.

Sexual Hx – Pt is heterosexual. She is sexually active.

Denies history of sexually transmitted diseases.

Review of Systems:

General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or generalized weakness/fatigue.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution. 

Head – Admits to chronic headaches. Denies vertigo, or head trauma. 

Eyes – Admits to photophobia that accompanies headaches. Denies lacrimation, pruritus, visual disturbances. Does not wear glasses. Does not recall when her last eye exam was or what his visual acuity or pressure is.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. 

Nose/sinuses – Denies discharge, epistaxis, or nasal polyps.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion 

Breast – Denies lumps, nipple discharge, or pain. 

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Does not recall when last dental exam was.

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND). 

Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation. Colonoscopy 2014, benign. 

Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain. 

Menstrual/Obstetrical – G1P0. Menarche age 13. LMP 1/27/23. Denies breakthrough bleeding/spotting of vaginal bleeding.

Musculoskeletal system – Denies muscle/joint pain from rheumatoid arthritis. Denies deformity or swelling, or redness.

Nervous –Denies seizures, headache, ataxia, loss of strength, change in cognition / mental status / memory, or weakness. 

Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes. 

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter 

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional. 

Physical

General: Female appears clean & well-groomed, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. No signs of acute distress, appears as stated age.

Vital Signs:     BP: (R) Seated 116/78                        P:  83 beats/min, regular

                               (L) Seated 120/80

                        R: 14 breaths/min, unlabored             O2 Sat: 97% Room Air

                        T: 36.8 degrees C (oral)

                        Height: 60 inches        Weight: 177 lbs          BMI: 34.6

Head, Skin, & Nails

Hair: Average quantity and distribution. Black color. Curly texture. No evidence of lice or seborrheic dermatitis.

Skin: Warm and moist, smooth texture, good turgor. 

Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities

Head: Normocephalic, atraumatic, non-tender to palpation throughout.

Eye Exam

Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis.  Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/25 OS, 20/25 OD,  20/25 OU. Visual fields full OU.  PERRLA, EOMs intact with no nystagmus.

Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU.  No AV nicking, hemorrhages, exudates or neovascularization OU.

Ear Exam

Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.

Nose & Sinuses Exam

Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.

Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth & Pharynx

Lips –   Pink, moist; no cyanosis or lesions. Non-tender to palpation.

Mucosa – Pink ; well hydrated. No masses; lesions noted.   Non-tender to palpation. No leukoplakia. 

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.  Non-tender to 

            Palpation; continuity intact. 

Teeth – Good dentition / no obvious dental caries noted. 

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. 

Tonsils present with no injection or exudate. Uvula pink, no edema, lesions

Neck Exam

Neck– Trachea midline.   No masses; lesions; scars; pulsations noted.   Supple; non-tender to

palpation.   FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted. 

Thorax & Lungs:

Chest – Symmetrical, no deformities, no trauma, Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.

Lungs –Clear to percussion & auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Cardiac Exam

Heart: JVP is 2.5cm above sternal angle with the head of the bed at 30 degrees. PMI in 5^th ICS in midclavicular line.Carotid pulses are 2+ bilaterally without bruits. Irregular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam: Abdomen flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebounding noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge. 

Pelvic Exam:

Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. No inguinal adenopathy.

Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. 

Neurologic: Mental status: Patient is alert and oriented to person, place and time. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally. 

Reflexes:

	Biceps	Triceps	Brachioradialis	Patellar	Ankle/Achilles	Babinski
Right	2+	2+	2+	2+	2+	absent
Left	2+	2+	2+	2+	2+	absent

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.

Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /

ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

DDx after H&P:

• Migraine w/o aura

Assessment: 37 y/o female w/ PMH of HLD, recurrent headaches, presenting for acute headache that has persisted since 6am this morning. No red flags based on history and no significant trauma. On exam patient exhibits photophobia. Patient has never seen a neurologist and has failed to obtain an outpatient MRI due to claustrophobia. A CT was obtained last year which was normal and will not repeat today especially with a normal neurological exam. 

Plan: Will prescribe Dexamethasone to prevent reoccurrence of migraines. Will also give patient a dose of ibuprofen in ED as patient had already taken 1000mg of Tylenol prior to arrival. Will also prescribe Reglan to take at home. Patient has a PCP and was explained to ask for medication for claustrophobia prior to MRI to help keep her calm. Patient states she will follow up with PCP for further evaluation of migraine and prophylactic medication. As patient is stable, safe to discharge with instructions to follow up with PCP and return precautions for worsening symptoms or concerns.