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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