CEFALEA EMERGENCIA SALUDESA

S.V.: T: ______PA: ______ / ______ P: ______

FR: _____ Sat O2 (%): ________

Informante: paciente / familiar / amigo

Anamnesis limitado por:
estado mental alterado / gravedad / intoxicacin / demencia / edad
Referido por: / primer nivel / familiar/ SSC/ auto referencia
Lleg por: caminando / silla ruedas / policia / vehiculo

MOTIVO DE CONSULTA
Cefalea / Migraa / Mareo / Rigidez cuello / Dolor facial
Problemas de Senos / Trauma crneo enceflico
ANAMNESIS
Cefalea de inicio: sbito / 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
Evolucina de forma: constante / intermitente
Actualmente el dolor esta: igual / peor / mejor / resuelto (hora:________ )
Sntomas ocurrieron durante: descanso / sexo / esfuerzo / trauma
Esta precedido de prdromos: escotomas / nausea / vmito/ninguno
Contexto: problema nuevo / recurrente / crnico
Ultimo episodio similar fue hace:
Frecuencia de episodio: raro /ocasional / frecuente ____epis. por mes/ao
Comparado con cefalea previa?: igual / no tan mal / peor / diferente
Trauma recinte?: no / si:_____________________________
Expuesto a medicamento o txico?: warfarina/ ASA / CO / Etanol
La caracterstica de la cefalea: no puede describir
urente / presin / 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
Sntomas Asociados: ninguno
Fiebre / debilidad / escalofros / anorexia / sudor / mareo / fotofobia
fonofobia / visin doble / visin borrosa / congestin nasal / gripe
dolor garganta / dolor de cuello / rigidez cuello / nausea / vmito / diarrea
tos / hemoptisis / palpitaciones / dolor precordial / sincope / convulsin
confusin / agitacin / obnubilacin / ansiedad / estrs / depresin
Se alivia: con nada
Acostado / quieto / uso medicamentos_______________________________
Se agrava por: nada
Cambio de posicin: acostado / sentado / parado /movimiento /

REVISIN DE SISTEMAS
__ Constitucional: fiebre / escalofros / mareos / baja de peso
__ Ojos: problemas visuales / visin borrosa / ojo rojo / escleras ictricas
__ ORL: dolor cuello / dolor garganta / dolor odo/ congestin
__ CV: dolor torxico / palpitaciones / ortopnea / disnea paroxstica 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 / reas dolorosas
__ Piel: rash / problemas de piel
__ Neurolgico: cefalea / convulsiones/ sincope / dficit neurolgico
__ Psiquitrico: stress / ansiedad / depresin / insomnio / alucinaciones
__ Hemato/Linfatico: heridas / sangrado / ndulos linfticos
__ Endocrino: poliuria /polidipsia /problema tiroideos/problema adrenal
__ Inmunolgico: Uso inmunodepresores / HIV / cncer
Todos negativos

Antecedentes Patolgicos: ninguno

Cluster / Migraa / Tensin / sinusitis /gripe
Sndrome Articulacin Temporo-Mandibular
Glaucoma / HTA / trauma ceflica / contusin
ceflica / concusin / ciruga ceflica 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
Ocupacin: desempleado estudiante
jubilado empleado:
_________________________
Vivienda: casa /departamento / rancho
Vive con: solo / compaero / hijos /
padres esposo(a)
Violencia Domstica: no si

Medicamentos: ninguno
Otro:

EXAMEN FSICO
Ortostatismo SV: O-- : PA= ________ P= _________
PA= ________ P= _________

Examen limitado por: condicin crtica del paciente / pcte no colabora

Estado general: alerta / letrgico / confundido / obnubilado
Orientado: en persona / tiempo espacio
Presenta ansiedad: leve / moderada / severa
Distres: leve / moderado / severo
Estado nutricional: Normal / caquctico / obeso
Hidratacin: conservada / deshidratado
Piel: ___ tibia y seca___ no ronchas, no eritema ___ no ronchas, no eritema
Linftico:
___ no adenopata cervical, axilar, inguinal
Ojos:___ parpados, esclera NL, Pupilas I,R,R., MEO ntegras ___ fondo NL
ORL, Cuello: ___ fosas nasales permeables, no secrecin___ Tmpanos 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
simtricos bilaterales.
Respiratorio: ___ no distres respiratorio___ Campos claros bilateralmente ___ pared torcica no
sensible
Gastrointestinal / Abdomen / Espalda
___ inspeccin y ruidos intestinales NL ___ suave, no sensible, no masas ___ Flancos y espalda no
sensibles
Musculo esqueltico: no deformidad, no sensibilidad___ fuerza muscular conservada
Neurolgico: ___ Pares craneales 2-12 respuesta normal___ fuerza motriz conservada y simtrica
___ sensibilidad superficial intacta
___ reflejos iguales y simtricos
Psiquitrico: ___ personalidad normal ___ no ideacin suicida u homicida

EXAMENES
___ EMO
___ Qumica Sangunea
___ TAC Cabeza (transferencia)

___ Biometra Hematica

___ Puncin Lumbar

DIAGNOSTICO DIFERENCIAL
Glaucoma
S. T.M.
Tensin/Estrs
Absceso Cerebral
Migraa
Sinusitis
Cluster
Meningitis
CO toxicidad
Contusin Cerebral Concusin
Encefalitis
Hematoma: subdural / epidural
Hemorragia subaracnoidea

DIAGNOSTICO:

TRATAMIENTO
Monitoreo no invasivo
O2 __________ L/minuto / con bigotera / mascarilla para mantener % sat > 94%
Solucin Salina I.V. ..ml .en bolo y luego Infusin 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 sbito dficit neurolgico
peor cefalea de mi vida

Disposicin:
Alta
Ingreso

Observacin

dolor que le despierta en la noche

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 HAs: ______________________________________________________
______________________________________________________________________________
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 ________________ HAs per month / year
HA history: migraine /cluster / tension / _____________________________________________
HA workup: none / CT scan _________ / MRI _______________ / neurology consult
Compared to other HAs: 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: cant describe
aching / dull / pain / pounding / pressure / sharp / squeezing / stabbing

vomito persistente

tearing / thunderclap HA / throbbing / worst HA of my life /

_______________________________________________________________________________
Severity: cans describe
At max (0 to 10): __________ mild / moderate / sever
Now (0 to 10): __________ none / mild / moderate / sever
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
Anxious: mild / moderate / severe
Nutritional status:___ WNL cachetic / obese

Oriented: person / place / time

Distress: mild / moderate / severe
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

: 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

___ external genitalia normal, no discharge

___ testicles normal, no masses, no hernia
___ prostate not enlarged, no masses
Comments:

___ no cervical motion tenderness

___ no cervical discharge
___ uterus, adnexa non-terder, no mass

Diagnostic Considerations: circle or write potential diagnoses

subarachnoid hemorrhage
glaucoma
TMJ syndrome
meningitis / brain abscess
migraine HA
cerebral sinus thrombosis
tumor
cluster HA
pseudotumor cerebri
subdural / epidural hematoma
tension HA
hypertensive headache
intracerebral bleed
sinusitis
dehydration
carbon monoxide poisoning
trigeminal neuralgia
temporal arteritis
shingles
Medical Decision Making: L1: straightforward; L2-3: low/complex; L4: mod; L5:high
Mark box
if test ordered or task done, check normals , circle and note abnormals
bronchitis
anxiety / 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

U/A: ___ WNL ___ WNL except:

CBC: ___ WNL ___ WNL except:

RBCs_______ WBCs ________

Chem: ___ WNL ___ WNL except

Bacteria

________
CSF fluid analysis:

Culture: Urine / Blood / CSF

Opening Pressure: __________

RBCs: __________ (tube # 4)
RBCs: __________ (tube # 1)
Xanthochromia: ___ neg pos
Total Protein: _____________
Glucose: _________________
WBCs: __________________
Segs _____ Lymphs _______

ESR: _____ WNL _________

Monos ____

INR: ____ WNL ___________

Gram Stain: ______________

__ Bands __ Segs ___ Lymphs __ Monos Anion Gap=

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

Disposition:
Discharge

hypertension
meningitis
subarachnoid bleed
cerebrovascular accident

time: __________________
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