Emergency Room Reports
Sample Name: Headache - Urgent Care Visit
Description: Migraine headache - The patient was seen in the urgent care.
(Medical Transcription Sample Report)
HPI: This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches.
MEDICATIONS: Tylenol for pain.
Vital Signs: BP 102/60 P 70 RR 20 T 98.2
HEENT: Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender.
Neck: Supple without meningismus.
Chest: Lungs clear; heart regular without murmur.
IMPRESSION: Migraine headache.
PLAN: See above.
Keywords: emergency room reports, photophobia, nausea, migraine headache, tylenol, migraine, headache,