Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on December 10, 2022 15:29  Verified By: on December 10, 2022 15:29  Encounter Info: 12/10/22 -     * Final Report *        Basic Information  Time Seen: 12/10/2022   Chief Complaint  Headache (Complaint of)  History of Present Illness     12/10/22 15:06:08  complains of headache since this morning not relieved by Aleve and Excedrin.  Patient is Influenza A + and beginning to feel better of majority of flu symptoms.  Nausea without vomiting.  Denies numbness/tingling/weakness/visual changes  Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  No shortness of breath,  no cough,  no wheeze Cardiovascular:  No chest pain,  no palpitations,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea,  no constipation Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness Psychiatric:  No anxiety,  no depression  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       37.1 DegC  Heart Rate:       84 bpm  Resp Rate:       18 br/min  BP:       120 / 71 mmHg  SpO2 (%):       99 %  O2 Device:       Room air  LMP:       11/06/2022     Height CM: 172.7 cm  Weight KG: 75.5 kg  Ideal Body Weight: 63.88 kg      General:  alert, no acute distress Skin:  warm, dry Head:  no trauma, normocephalic Neck:  trachea midline, no adenopathy, no tenderness Eye:  normal conjunctiva, clearsclera Cardiovascular:  regularrate and rhythm, normalperipheral perfusion Respiratory:  Lungs CTA, respirations non-labored Chest wall:  no deformity Gastrointestinal:  soft, non-distended, no tenderness _, no guarding _ Extremities:  no deformity, no trauma Neurological:  oriented x4  , LOC appropriate for age, CNII-XII intact, motor strength equal and normal bilaterally, sensation equal and normal bilaterally  , speech normal Psychiatric:  Cooperative ,  appropriate for ageaffect  , normal  judgement,  normal psychiatric thoughts  Medical Decision Making     Chart Review: ED RN notes, prior chart review  12/10/22 15:29:39 Disposition: discharged Dr. _ , Location:   Counselled: Patient, Family, Discussed diagnosis, diagnostic studies, prescriptions, follow up plan and strict ED return instructions. All additional questions were answered.             Condition     stable  Assessment/Plan       1. Headache   R51.9    2. Influenza A   J10.1    Orders:   Discharge Patient   Patient Education   Influenza (Adult)  Follow Up        With  When  Contact Information        Follow up with primary care provider Within 3 to 5 days       Additional Instructions:          Chronic Problem List    ADD (attention deficit disorder)  Kidney stone  Procedure/Surgical History  ?Cholecystectomy Laparoscopic (04/2015) ?Lithotripsy    Medications  Home Medications (6) Active cetirizine 10 mg oral tablet , TK 1 T PO  QD FOR CONGESTION Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily Mononessa 0.25 mg-35 mCg oral tablet , TK 1 T PO  QD Naprosyn 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID, Take one tablet 2 times a day daily with food always Naprosyn 500 mg oral tablet 500 mg = 1 Tablet, PRN, Orally, BID Vyvanse 40 mg oral capsule 40 mg = 1 Capsule, Orally, Daily  Medication Administration   Given  ketoROLAC, 60 mg, IM  promethazine, 25 mg, Orally  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Former use, quit more than 90 days ago.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).      Diagnostic Results  No qualifying data available.        Signature Line Electronically Signed on 12/10/22 15:29 ________________________________________________________   1. ED VISIT ON 12/07/2022 FLU A +  2. ED VISIT ON 12/10/2022