Minor Urgent Care (Migraine Form)
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Chief Complaint:
Patient presents with headache consistent with migraine
History of Present Illness
Patient reports headache described as throbbing, unilateral/bilateral, with associated light sensitivity, sound sensitivity and/or nausea. Patient reports prior history of migraines, denies vision loss, weakness or confusion. No recent head trauma.
How long ago did the onset of your current migraine begin?
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Please provide an estimated time in hours or days
On a scale of 1-10, how severe is your current headache?
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Least
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2
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Most
10
1 is Least, 10 is Most
Review of Symptoms (ROS):
Constitutional: Denies fever, chills and weight loss. HEENT: Reports headache, light sensitivity. Denies sinus pain, sore throat or ear pain. Neurological: Reports headache, photophobia/phonophobia. Denies weakness, numbness, confusion, slurred speech, seizure activity. Cardiovascular: Denies chest pain, palpitations, syncope. Respiratory: Denies cough, shortness of breath. Gastrointestinal: Reports nausea (if present). Denies vomiting, diarrhea, abdominal pain. Skin: Denies rash or new skin changes.
Physical Exam:
General: Alert, oriented, appears uncomfortable but in no acute distress. HEENT: Normocephalic, atraumatic; PERRLA; no sinus tenderness. Neuro: Cranial nerves II-XII grossly intact; normal strength and sensation in all extremities; normal coordination and gait. Heart: Regular rate and rhythm; no murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, non-distended. Skin: Warm, dry, intact.
Assessment:
1. Acute migraine headache 2. Rule out secondary headache causes (serious pathology) 3. Symptomatic management
Plan:
Supportive care and trigger avoidance discussed. Offered in-office migraine relief injections/medications as appropriate. Encourage hydration, rest, and dark/quiet environment. Patient has been educated on red flag symptoms and when to seek emergency care. Patient verbalized understanding and agrees with plan.
Prescribed medications:
Injections given in office:
Red Flag Symptoms (Patient Denies):
Sudden onset "thunderclap" headache (worst of life). Vision changes or vision loss. Weakness, numbness, or difficulty speaking. Confusion or altered mental status. Seizure activity. Fever with neck stiffness. Recent head trauma with worsening headache. Persistent vomiting with inability to tolerate fluids. Rapidly worsening or different pattern headache.
Provider Signature (Stacy Sims, FNP-C)
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