Download EMERGENCIA_CEFALEA

CEFALEA EMERGENCIA SALUDESA
S.V.: T: ______PA: ______ / ______ P: ______
FR: _____ Sat O2 (%): ________
Informante: paciente / familiar / amigo
Anamnesis limitado por:
estado mental alterado / gravedad / intoxicación / demencia / edad
Referido por: / primer nivel / familiar/ SSC/ auto referencia
Llegó por: caminando / silla ruedas / policia / vehiculo
Consentimiento de reanimación:
MOTIVO
DErean.
CONSULTA
ninguna / NO
/ rean. TOTAL / medidas de soporte
Cefalea / “Migraña” / Mareo / Rigidez cuello / Dolor facial
Problemas de Senos / Trauma cráneo encefálico
ANAMNESIS
Cefalea de inicio: súbito / gradual / incierto
que inicia a las…….horas del dia….. hoy / ayer
__________ minutos / horas / dias / semanas / meses antes de llegar
Se localiza en: difusa / cara / frontal / occipital / cuello / temporal / ojo
(derecho / izquierdo)
La cefalea de irradia al: cuello / espalda / cara
Evolucióna de forma: constante / intermitente
Actualmente el dolor esta: igual / peor / mejor / resuelto (hora:________ )
Síntomas ocurrieron durante: descanso / sexo / esfuerzo / trauma
Esta precedido de pródromos: escotomas / nausea / vómito/ninguno
Contexto: problema nuevo / recurrente / crónico
Ultimo episodio similar fue hace:
Frecuencia de episodio: raro /ocasional / frecuente ____epis. por mes/año
Comparado con cefalea previa?: igual / no tan mal / peor / diferente
Trauma reciénte?: no / si:_____________________________
Expuesto a medicamento o tóxico?: warfarina/ ASA / CO / Etanol
La característica de la cefalea: no puede describir
urente / presión / como martillo / como “cuchillo” / opresivo
“la peor cefalea en toda mi vida”
Gravedad: no puede describir
En el peor momento (0-10): __________ leve / moderado / severo
Actualmente (0-10): __________ nada / leve / moderado / severo
Síntomas Asociados: ninguno
Fiebre / debilidad / escalofríos / anorexia / sudor / mareo / fotofobia
fonofobia / visión doble / visión borrosa / congestión nasal / gripe
dolor garganta / dolor de cuello / rigidez cuello / nausea / vómito / diarrea
tos / hemoptisis / palpitaciones / dolor precordial / sincope / convulsión
confusión / agitación / obnubilación / ansiedad / estrés / depresión
Se alivia: con nada
Acostado / quieto / uso medicamentos_______________________________
Se agrava por: nada
Cambio de posición: acostado / sentado / parado /movimiento /
REVISIÓN DE SISTEMAS
__ Constitucional: fiebre / escalofríos / mareos / baja de peso
__ Ojos: problemas visuales / visión borrosa / ojo rojo / escleras ictéricas
__ ORL: dolor cuello / dolor garganta / dolor oído/ congestión
__ CV: dolor toráxico / palpitaciones / ortopnea / disnea paroxística nocturna / edemas pre tibiales
__ Respiratorio: disnea / sibilancias / hemoptisis / tos
__ GI: dolor abdominal / nausea / vomito/ diarrea / sangre heces
__ GU: disuria / urgencia / poliuria / hematuria /
__ Musculoesqueletico: mialgias / artralgias / áreas dolorosas
__ Piel: rash / problemas de piel
__ Neurológico: cefalea / convulsiones/ sincope / déficit neurológico
__ Psiquiátrico: stress / ansiedad / depresión / insomnio / alucinaciones
__ Hemato/Linfatico: heridas / sangrado / nódulos linfáticos
__ Endocrino: poliuria /polidipsia /problema tiroideos/problema adrenal
__ Inmunológico: Uso inmunodepresores / HIV / cáncer
Todos negativos
Antecedentes Patológicos: ninguno
Cluster / Migraña / Tensión / sinusitis /gripe
Síndrome Articulación Temporo-Mandibular
Glaucoma / HTA / trauma cefálica / contusión
cefálica / concusión / cirugía cefálica hemorragia
subaracnoide
Se realizo TAC o RM hace…..con el siguiente
resultado
Alergia: ninguna / latex / PCN / sulfa
/ contraste Rayos X
Antecedentes Familiares: desconocidos
Hemorragia subaracnoide / HTA / ECV
Otro:
Antecedentes Sociales: desconocidos
Alcohol: positivo, negativo
Ocupación: desempleado estudiante
jubilado empleado:
_________________________
Vivienda: casa /departamento / rancho
Vive con: solo / compañero / hijos /
padres esposo(a)
Violencia Doméstica: no si
Medicamentos: ninguno
Otro:
EXAMEN FÍSICO
Ortostatismo SV: O-- : PA= ________ P= _________
PA= ________ P= _________
:
Examen limitado por: condición crítica del paciente / pcte no colabora
Estado general: alerta / letárgico / confundido / obnubilado
Orientado: en persona / tiempo espacio
Presenta ansiedad: leve / moderada / severa
Distres: leve / moderado / severo
Estado nutricional: Normal / caquéctico / obeso
Hidratación: conservada / deshidratado
Piel: ___ tibia y seca___ no ronchas, no eritema ___ no ronchas, no eritema
Linfático: ___ no adenopatía cervical, axilar, inguinal
Ojos:___ parpados, esclera NL, Pupilas I,R,R., MEO íntegras ___ fondo NL
ORL, Cuello: ___ fosas nasales permeables, no secreción___ Tímpanos NL, no abombados
___ faringe no eritema, no pus___ cuello suave, no soplos o masas
Cardiovascular: ___ FC y ritmo normales ___ R1&R2 normales, no soplo ___ pulsos iguales y
simétricos bilaterales.
Respiratorio: ___ no distres respiratorio___ Campos claros bilateralmente ___ pared torácica no
sensible
Gastrointestinal / Abdomen / Espalda
___ inspección y ruidos intestinales NL ___ suave, no sensible, no masas ___ Flancos y espalda no
sensibles
Musculo esquelético: no deformidad, no sensibilidad___ fuerza muscular conservada
Neurológico: ___ Pares craneales 2-12 respuesta normal___ fuerza motriz conservada y simétrica
___ sensibilidad superficial intacta
___ reflejos iguales y simétricos
Psiquiátrico: ___ personalidad normal ___ no ideación suicida u homicida
EXAMENES
___ EMO
___ Química Sanguínea
___ TAC Cabeza (transferencia)
___ Biometría Hematica
___ Punción Lumbar
DIAGNOSTICO DIFERENCIAL
Glaucoma
S. T.M.
Tensión/Estrés
Absceso Cerebral
Migraña
Sinusitis
Cluster
Meningitis
CO toxicidad
Contusión Cerebral Concusión
Encefalitis
Hematoma: subdural / epidural
Hemorragia subaracnoidea
DIAGNOSTICO:
TRATAMIENTO
Monitoreo no invasivo
O2 __________ L/minuto / con bigotera / mascarilla para mantener % sat > 94%
Solución Salina I.V. …..ml .en bolo y luego Infusión continua _______ ml/hora
Tempra / Ibuprofeno / Diclofenaco ______mg VO / IM / IV/ I.R.
Sosegon / Tramal / Sistalgina ________mg VO / IM / IV
Metoclopramide 10mg IV
Considerar TAC si hay:
inicio súbito déficit neurológico dolor que le despierta en la noche
persistente ”peor cefalea de mi vida”
Disposición:
Alta
Ingreso
Observación
Transferencia
Medico:___________________________________________
SLMC
SLSS
WAMH
Headache
# 05
Check ( )for normals, circle positives , slash negatives,
for test ordered or task performed
Date: ________________ Time Seen: __________ Age: _________ PMD: ________________
Temp: ____________ BP: ________ / _________P: ________ RR: ______ POX (%): ________
Chief Complaint: headache / “migraine HA” / neck stiffness / dizziness
lightheadedness / facial pain / sinus problems / head trauma / _________________________
HPI: L1-3: 1-3 elements; L4-5: 4+ elements
Historian: patient / family / friend / EMS / interpreter /
Hx & ROS limited by: altered mental status / acuity / intoxication / dementia / age
Referred by. Self / clinic / PMD / family / EMS /
Arrived by: EMS / walk-in / wheelchair / police / car driven by: self / friend / family /
Advanced Directive: none / DNR / “full code” / comfort care /
Onset: sudden / crescendo-onset HA / gradual / unsure
Began: _____________________ time ____________________ date today / yesterday
_______________________ minutes / hrs / days / weeks / months
prior to arrival
Location: diffuse / frontal / occipital / face / neck
(right / left ) temporal / eye /
Radiation: neck / back / face /
Course / Timing / Duration: constant / intermittent
Course: same / fluctuating / worse / improved / resolved (time:______________________ )
Duration, frequency of HA’s: ______________________________________________________
______________________________________________________________________________
Symptoms occurred: rest / exertion / during sex / “woke up with HA” / trauma
Prodrome: none / scintillating scotoma / fortification spectrum / nausea / vomiting
______________________________________________________________________________
Context: new problem / recurrent / chronic
If recurrent HA, last HA of similar quality: ___________________________________________
HA frequency: rare / occasional / frequent ________________ HA’s per month / year
HA history: migraine /cluster / tension / _____________________________________________
HA workup: none / CT scan _________ / MRI _______________ / neurology consult
Compared to other HA’s: same / not as bad / worse / worst ever / different type
Recent trauma or head injury? ____ no yes: _________________________________________
Medication or Toxin Exposure: coumadin / plavix / aspirin / ETOH / cocaine / CO
Character / Quality: can’t describe
aching / dull / “ pain” / pounding / pressure / sharp / squeezing / stabbing
tearing / “thunderclap” HA / throbbing / “worst HA of my life” /
_______________________________________________________________________________
Severity: can’s describe
At max (0 to 10): __________ mild / moderate / sever
Now (0 to 10): __________ none / mild / moderate / sever
vomito
Associated Sx: ___ none
fever / weakness / dizziness / chills / malaise / blurred vision / double vision
photophobia / phonophobia / nasal congestion / URI Sx / flu Sx / facial pain
sore throat / neck pain / neck stiffness / cough / nausea / vomiting / diarrhea
syncope / seizure / confusion / obtunded / agitation / behaviour change / stress
anxiety / depression / _____________________________________________________________
Alleviated / Relieved by: ___ nothing
Lying still / medications: _________________________________________________________
Aggravated / Exacerbated by: ____ nothing
Change in position / head movement / stting up / standing / ______________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Past Medical, Family, Social hx:L1-4: 1 area; L5: 2 of 3 areas
Allergy: __ NKDA see ED record / latex / PCN / sulfa / contrast medium /
_________________________________________________________________
Medications: ___ none see ED record
aspirin / digoxin / coumadin
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
PMH / Surgical Hx: ___ none unsure / see ED record
migraine HA / cluster HA / “tension” HA / sinusitis / URI / glaucoma
HTN / hypercholesterolemia / NIDDM / IDDM / CAD / MI
afib / CHF / COPD / DVT / PE / PUD / GI bleed
UTI / TIA / CVA / hypothyroidism / LBP / cancer
head trauma / concussion / brain surgery / ventricular-peritoneal shunt
appendectomy / cholecystectomy / CABG
pacemaker / AICD / cardiac cath _____________ / stress test _______________
________________________________________________________________
_______________________________ / Tetanus immunization current: yes / no
Social Hx: unknown
Tobacco use: _____ no yes: _____ cigarettes / packs per day / week
ETOH: _____ no yes: ______ drinks per day / week Last ETOH: _________
Drug use: _____ no yes: cocaine / marijuana / ________________________
Occupation: unemployed / student / retired / employed: _________________
_________________________________________________________________
Lives: house / apartment / homeless / homeless shelter / group home /
assisted living / nursing home / ______________________________________
Living situation: alone / significant other / children / parents /
Domestic Violence: ____ no yes:_____________________________________
Family HX: noncontributory / unknown / HTN / subarachnoid hemorrhage
CVA /
ROS: L1-3: 1 system; L4: 2-9 systems; L5: 10+systems
All 14 systems reviewed: __ neg __ neg except as per HPI and/or circle below
__ Constitutional: fever / chills / malaise / weight loss
__ Eyes / Mouth: visual problems / photophobia / redness / dental pain
__ ENT: sore throat / congestion / ear pain / TMJ problems
__ CV: chest discomfort / palpitations / orthopnea / PND / ankle swelling
__ Respiratory: SOB / DOE / wheezing / hemoptysis / cough
__ GI: abdominal discomfort / nausea / vomiting / diarrhea / tarry stools /
rectal bleeding / constipation
__ GU: dysuria / urgency / frequency / hesitation / hematuria / kidney problems)
LMP: _________________: ___ WNL abnormal
__ Musculoskeletal: myalgias / painful areas:
__ Skin: rash / skin problems
__ Neurologic: weakness / blackouts / numbness / tingling / seizures /
Confusion / neck stiffness
__ Psychiatric: stress / anxiety / depression / insomnia / hallucinations
__ Hematology / Lymphatic: bruising / bleeding / swollen lymph nodes
__ Endocrine: polyuria / polydipsia / thyroid problems
__ Immunology / Allergy: HIV / Immunosuppressant therapy / cancer
Saludesa
SLMC
SLSS
WAMH
Headache # 05
Physical Exam: L2-3: 2-4 organ/areas; L4: 5-7 organ/areas; L5: 8+ organ/areas
VS Reviewed
Exam limited by: urgency of condition / patient uncooperative
General: alert / lethargic / confused / obtunded
Oriented: person / place / time
Anxious: mild / moderate / severe
Distress: mild / moderate / severe
Nutritional status:___ WNL cachetic / obese
Hydration: ___ WNL dehydrated
Orthostatic VS: O- : BP= _______ P= ________
Eyes:
___ lids, sclera WNL, PERRL bil , EOM intact
___ funduscopic exam WNL bil.
ENT, Neck:
___ nares patent, no discharge
___ TM not injected, no bulging
___ pharynx not injected, no exudates
___ neck supple, no bruits or masses
Cardiovascular:
___ regular rate and rhythm
___ normal S1&S2, no murmur
___ pulses equal and symmetric bilaterally
Respiratory:
___ no respiratory distress
___ lungs CTA bilaterally
___ chest wall non-tender
Gastrointestinal / Abdomen / Back
___ inspection and bowel sounds normal
___ soft, non-distended, no masses
___ no flank or back tenderness
___ rectal exam normal, heme neg. stool
Genitourinary, Male
___ external genitalia normal, no discharge
___ testicles normal, no masses, no hernia
___ prostate not enlarged, no masses
Comments:
: BP= ________ P= _________
Musculoskeletal:
___ no deformity, no tenderness
___ muscle strength grossly intac
Skin:
___ warm and dry
___ no rash, no erythema
___ no peripheral edema
Neurologic:
___ CN II-XII grossly intac
___ motor strength equal and symmetric
___ light touch sensation intac
___ reflexes equal and symmetric
___ no nuchal rigidity, no neck stiffness
Psychiatric:
___ affect and mood normal
___ no suicidal or homicidal ideation
Lymphatic:
___ no cervical lymphadenopathy
___ no axillary lymphadenopathy
___ no inguinal lymphadenopathy
Genitourinary, Female
___ external genitalia without lesions
___ no cervical motion tenderness
___ no cervical discharge
___ uterus, adnexa non-terder, no mass
Diagnostic Considerations: circle or write potential diagnoses
subarachnoid hemorrhage
meningitis / brain abscess
tumor
subdural / epidural hematoma
intracerebral bleed
carbon monoxide poisoning
temporal arteritis
glaucoma
migraine HA
cluster HA
tension HA
sinusitis
trigeminal neuralgia
shingles
TMJ syndrome
cerebral sinus thrombosis
pseudotumor cerebri
hypertensive headache
dehydration
Medical Decision Making: L1: straightforward; L2-3: low/complex; L4: mod; L5:high
Mark
box
if test ordered or anxiety
task done,
check normals , circle and note abnormals
bronchitis
/ pani
Monitor
ECG: ready by ED MD and compared to ECG from _________________
Rhythm: NSR / ST / a-fib / paced Rate: ______ Intervals: ____ WNL QRS:____ WNL
ST-T wave: ___ WNL: _____________________________________________________
Other: ECG unchanged / ___________________________________________________
Lab:
Lab Results Reviewed
CBC: ___ WNL ___ WNL except:
Chem: ___ WNL ___ WNL except
U/A: ___ WNL ___ WNL except:
RBCs_______ WBCs ________
Bacteria ________
CSF fluid analysis:
Opening Pressure: __________
RBCs: __________ (tube # 4)
RBCs: __________ (tube # 1)
Xanthochromia: ___ neg pos
Total Protein: _____________
__ Bands __ Segs ___ Lymphs __ Monos Anion Gap=
Glucose: _________________
WBCs: __________________
Culture: Urine / Blood / CSF
Segs _____ Lymphs _______
ESR: _____ WNL _________
Monos ____
INR: ____ WNL ___________
Gram Stain: ______________
CO level: ____ WNL _______
Radiology:
1- Head CT scan _____________________________________________________
____ WNL _______________________________________________________
2- _________________________________________________________________
____ WNL ______________________________________________________
1- Read by: ED MD / Radiology Report
2- Read by: ED MD / Radiology Report
Treatment / Management Options / Course:
O2 at __________ L/minute / % FiO2 (NC, face mask, _____________________ )
IV cap / infusion (NS, _____); Bolus ______________ mL; Rate _______ mL/hr
Acetaminophen / Ibuprofen _________________ mg PO
Vicodin / Percocet 1 / 2 PO
Zofran 2 / 4 ____ mg IV / PO
Benadril 25 / 50 mg IV / PO
Compazine 5 / 10 mg IV / IM / PO
Haldol / Droperidol 2.5 / 5 mg IV / IM
Benadryl 25 / 50 mg IV / IM / PO
Toradol 15 / 30 / 60 mg IV / IM
Morphine sulphate _____ mg IV ; repeated x 1 2 3 4 ; total dose= ___________ mg
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Pain Level: ___ / 10 @ _________ ; ___ / 10 @ _________ ; ____ / 10 @ ___________
Course: same / worse / improved / resolved
Patient evaluated and examined by MD
Level: ___1 ____ 2 ____ 3 ___ 4 ___ 5 _____________________ _______________
physician #
PA #
Critical Care Time (excluding procedures) = _______________________ minutes
ED Observation Admission
ED Fast Track
Consultation / Other Data Reviewed:
Consulted Dr(s): _______________________________________ @ ______________
Suggests: admit / discharge / will see: _____________________________________
Case discussed with: patient / family / Radiologist / PMD / ______________________
Reviewed: Nursing Home / EMS / RN / Old Records from _______________________
Clinical Impression (circle or write diagnoses):
headache
migraine headache
tension headache
nausea / vomiting
dehydration
fever / sinusitis
hypertension
meningitis
subarachnoid bleed
cerebrovascular accident
Disposition:
time: __________________
Discharge
Admit: OBS beb / general / Tele / medical / surgical / ICU
Transfer ____________________________ to Dr._________________________
Follow up: PMD / ______________________ in / on _______ days / prn / as scheduled
Condition: good / stable / serious / critical Isolation: none / droplet / contact / airborne
Restrictions: off work / limited duty / gym / school for __________________________
Discharge Instructions given: verbal / written / via interpreter
Discharge Rx: ibuprofen / vicodin / percocet /
____________________________________ MD / DO / PA Date ______________
____________________________________ MD / DO / PA Date ______________
____________________________________ MD / DO / PA Date ______________
Addendum: _______
template complete, dictation pending
See: template / dictation
template complete, full / partial dictation complete
See RN Notes & ED Chart
template complete, no dictation needed