bouncebacks

CC: Headache

First visit

HPI: 29 year old female with a prior history of headaches, presented with two days of gradual onset, atraumatic, right sided headache that is throbbing in nature. The patient reported heaviness about the eye but no visual changes or disturbances. No neck pain, fevers, chills. She described feeling slightly light-headed but no balance loss. She had a mechanical trip and fall yesterday without head trauma, and her headache had been present for a day prior to the fall.
ROS: otherwise normal.
PMH/PSH: headaches, depression, anxiety, asthma
SH: no smoking, no etoh, no drugs
Allergies: Penicillin (rash)

Pertinent Exam
Vitals: 98.6F, BP: 156/85 P: 101, RR: 16, O2: 98%RA
Gen: A&Ox3, well-developed, well-nourished
HEENT: normocephalic, atraumatic, conjunctiva wnl, EOM wnl, PERRL, normal fundoscopic exam, crisp optic discs, normal ROM neck/supple
Chest: wnl
Abd: wnl
Musculoskeletal: wnl
Neuro: CN2-12 intact, normal reflexes, normal muscle tone, normal coordination

Labs: Serum HCG negative

Imaging: None ordered

ED Course: The patient was believed to be experiencing a migraine headache. She had no evidence of head trauma, no signs of infectious etiology, and had no clinical findings or hx for SAH. She was administered Toradol, IVF and Reglan, and discharged with instructions to follow up with neurology and possibly have an outpatient MRI.

Discharge Dx: Headache […]