Occipital neuralgia Personal history of nicotine dependence
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: NEUROSURGERY
 
Allergies: 
No Allergies/ADRs on File
 
Attending: ___.
 
Chief Complaint:
Headache
 
Major Surgical or Invasive Procedure:
___- Diagnostic Angiogram- Negative
 
History of Present Illness:
___ year old male who presented to OSH with left sided
frontal headache x 5 days after working out at the gym. The
patient reports he generally doesn't have trouble with 
headaches,
and states he took some Tylenol initially with relief although
reports over the course of several days Tylenol was no longer
relieving his headache therefore he presented to ___ on ___ for further evaluation. A NCHCT was
performed and was negative for hemorrhage therefore he was
discharged to home. The patient returned the following day as
headache symptoms persisted. He underwent an MRI/MRA which
revealed no acute intracranial process, however there is a note
of minute focus of relatively nodular signal in the region of 
the
anterior communicating artery on MR angiography which measures
approximately 2mm and could represent prominent infundibulum at
the origin of the anterior communicating artery from left A1. A 
2
mm Microaneurysm is possible here. He also underwent an LP which
revealed 120 RBS in tube 1 with 1 WBC and 120 RBCs in Tube 3 
with
less than 1 WBC. The patient was then transferred to ___ for
further Neurosurgical evaluation and diagnostic angiogram with
possible intervention. 
 
Past Medical History:
BPH, Appendicitis requiring appendectomy, Hernia repair

 
Social History:
___
Family History:
No history of aneurysms. 

 
Physical Exam:
On Discharge ___: Eyes open spontaneously, Aox3, PERRL ___ 
bilaterally, face symmetric, tongue midline, no pronator drift. 
Speech clear and comprehension intact. Moves all extremities 
with full strength ___.  Right groin dressing clean dry and 
intact. Groin soft, no hematoma. Distal pulses intact to 
bilateral lower extremities. 
 
Pertinent Results:
CAROTID/CEREBRAL BILAT Study Date of ___ 1:58 ___ 
IMPRESSION: 
1. Diagnostic cerebral angiogram within normal limits, with 
fenestration of the A-comm. 
RECOMMENDATION(S): 
1. Neurology consultation for headaches management. 

 
Brief Hospital Course:
___ year old male with 5 days of headaches who was transferred 
from OSH with concern of 2mm ACA aneurysm.

#Headaches:
The patient was taken for a diagnostic angiogram upon arrival to 
___. It was within normal limits, and demonstrated a 
fenestration of the A-comm. The patient recovered in the PACU 
and was transferred to the ___ when stable. On Post-operative 
check he was neurologically intact and his right groin was soft 
and there was no concern for hematoma. Distal pulses were 
intact. Neurology was consulted to assess for further causes of 
headaches. Notes and lab results were obtained from outside 
hospital Neurology consult for interpretation by the Neurology 
team. It was determined by Neurology that the patients headaches 
were caused by Occipital Neuralgia. It was recommended that he 
was to be started on Gabapentin 300 mg po Q HS. Detailed 
instructions were given to him for management of pain and when 
to stop gabapentin as well as when to follow up as an 
outpatient. This was all listed in his discharge information. 

The patient was cleared for safe discharge to home by the 
Neurosurgery service. He was given prescriptions and follow up 
information. 
 
Medications on Admission:
None
 
Discharge Medications:
1.  Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Pain - 
Moderate 
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ 
capsule(s) by mouth every eight (8) hours Disp #*40 Capsule 
Refills:*0 
2.  Docusate Sodium 100 mg PO BID  
3.  Gabapentin 300 mg PO QHS 
As instructed on discharge instructions 
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30 
Capsule Refills:*1 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Headache
Occipital Neuralgia 

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Discharge Instructions
Dr. ___ 

___
 You may gradually return to your normal activities, but we 
recommend you take it easy for the next ___ hours to avoid 
bleeding from your groin.
 Heavy lifting, running, climbing, or other strenuous exercise 
should be avoided for ten (10) days. This is to prevent bleeding 
from your groin.
 You make take leisurely walks and slowly increase your 
activity at your own pace. ___ try to do too much all at once.
 Do not go swimming or submerge yourself in water for five (5) 
days after your procedure.
 You make take a shower.

Medications
 Resume your normal medications and begin new medications as 
directed.
 You may use Acetaminophen (Tylenol) for minor discomfort if 
you are not otherwise restricted from taking this medication. 
Please do not take this with Fioricet as this contains 
acetaminophen. Please do not exceed greater than 4 grams of 
acetaminophen in 24 hours.
 If you take Metformin (Glucophage) you may start it again 
three (3) days after your procedure.

Care of the Puncture Site
 You will have a small bandage over the site.
 Remove the bandage in 24 hours by soaking it with water and 
gently peeling it off.
 Keep the site clean with soap and water and dry it carefully.
 You may use a band-aid if you wish.

What You ___ Experience:
 Mild tenderness and bruising at the puncture site (groin).
 Soreness in your arms from the intravenous lines.
 Fatigue is very normal.

When to Call Your Doctor at ___ for:
 Severe pain, swelling, redness or drainage from the puncture 
site. 
 Fever greater than 101.5 degrees Fahrenheit
 Constipation
 Blood in your stool or urine
 Nausea and/or vomiting

Call ___ and go to the nearest Emergency Room if you experience 
any of the following:
 Sudden numbness or weakness in the face, arm, or leg
 Sudden confusion or trouble speaking or understanding
 Sudden trouble walking, dizziness, or loss of balance or 
coordination
 Sudden severe headaches with no known reason

Occipital Neuralgia 

  You were seen and evaluated by the Neurology service while at 
___ for further evaluation of your headaches. It was 
determined that you are currently suffering from Occipital 
Neuralgia. 
  Please begin taking Gabapentin 300 mg by mouth every night at 
bedtime. You have been given a prescription for this medication 
at the time of discharge.
 If you experience relief of headache with the Gabapentin 
please continue to take this medication for an additional 4 
weeks AFTER your headache symptoms have resolved. 
 If you do not have relief of headache after ___ weeks please 
follow up with the local pain clinic or you may follow up with 
Dr. ___ Neurology at ___ for a possible occipital 
nerve block. Dr. ___ phone number is ___. 
 
Followup Instructions:
___

{'headache': ['Occipital neuralgia'], 'tenderness': ['Occipital neuralgia'], 'bruising': ['Occipital neuralgia'], 'soreness': ['Occipital neuralgia'], 'fatigue': ['Occipital neuralgia'], 'pain': ['Occipital neuralgia'], 'swelling': ['Occipital neuralgia'], 'redness': ['Occipital neuralgia'], 'drainage': ['Occipital neuralgia'], 'fever': ['Occipital neuralgia'], 'constipation': ['Occipital neuralgia'], 'blood in stool or urine': ['Occipital neuralgia'], 'nausea and/or vomiting': ['Occipital neuralgia'], 'numbness or weakness in the face, arm, or leg': ['Occipital neuralgia'], 'confusion or trouble speaking or understanding': ['Occipital neuralgia'], 'trouble walking, dizziness, or loss of balance or coordination': ['Occipital neuralgia'], 'severe headaches': ['Occipital neuralgia']}