Headache / Migraine

SOAP Note

Subjective (S)

CC: Severe headache x 24 hours HPI: 34 y/o female with known migraine history. Right-sided, retro-orbital, throbbing, 9/10. Visual aura preceded headache. Photophobia, phonophobia, nausea. Failed sumatriptan 100mg.

Objective (O)

Vitals: BP 122/76, HR 72, RR 16 General: Lying in dark room, eyes closed Neuro: Alert, oriented x 4, CN II-XII intact, motor 5/5, no neck stiffness, negative Kernig's/Brudzinski's

Assessment (A)

Primary Dx: Migraine with aura, intractable Typical migraine features, no red flags for secondary headache.

Plan (P)

1. IV fluids NS 1L 2. Prochlorperazine 10mg IV + Diphenhydramine 25mg IV 3. Ketorolac 30mg IV Discharge: Rescue medication, headache diary Follow-up: Neurology 2 weeks