discussion

Melisa Tennies

Hello, all, 

The patient presents with a chief complaint of the following: Headache (4/10),

HPI: throbbing pain for the past 2 hours, palpable pulse in the temple. Denies fever, no change in vision, denies cold/sinus symptoms. PMH: History of scoliosis, managed with a Charleston brace, a broken toe and sports-induced asthma. Medications: None. NKDA. Hospitalizations: None. Eye exam completed 2 years ago. Social and Personal History: smokes no tobacco, occasional wine (once a month), denies illicit drugs. Single, lives alone. Traveled to UK and Caribbean in past 3 months. ROS: Headache (nervous system). Denies sinus congestion/fever/change in vision. Focused vs. Comprehensive Assessment This is an example of a focused assessment, which would be most appropriate for this encounter. This exam would focus on the neurological and cardiovascular systems, as the chief complaint is a headache, and the description of the pain (throbbing with a pulse in the temple) would raise concerns about a vascular etiology (e.g., migraine, cluster headache, or temporal arteritis). Focused assessments are done when a patient presents for a specific complaint, as opposed to a comprehensive evaluation that is done at a new patient's annual physical or when a broad baseline is desired (Jarvis, 2020). In this case, it would not be necessary to conduct a comprehensive review of all systems because the patient is otherwise healthy (only 2 systems noted in PMH, no pertinent negatives or systemic complaints). Additional neurological questions, such as any numbness/weakness, photophobia, or phonophobia, would be appropriate given this patient’s chief complaint of a headache. As this headache seems concerning for a vascular etiology, I would also assess for vascular risk factors in the history (hypertension, positive family history for stroke/aneurysm). Additional systemic review is likely not needed, but the questions noted above would be appropriate given this patient’s symptoms. References Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier. Bickley, L. S., & Szilagyi, P. G. (2021). Bates’ guide to physical examination and history taking (13th ed.

Beth Brothers

This patient is being seen acutely for a focused assessment related to a headache. A focused assessment is appropriate for established patients and patients seeking urgent care to address focused concerns/symptoms narrowed to a specific body system, examined as thoroughly as possible (Bickley, 2023).

Chief Complaint:  throbbing headache

History of Present Illness:

Onset not provided

Location - head

Duration – at least 2 hours

Characterized as throbbing

Alleviated by not provided

Aggravated by not provided

Radiates – can feel pulse in temple

Treatment not provided

Severity: pain is 4/10

Summary – Pt complains of headache, 4/10, throbbing last 2 hours. No fever. No vision changes. In UK and Caribbean within last 3 months.

 

Past Medical History:  Sports-induced asthma. Denies past hospitalizations. Scoliosis corrected

            with Charleston brace. Broken toe. Eye exam 2023.

Medication history:  Denies current medication usage

             Allergies:  NKDA

Personal and Social History:  Single, living alone. Denies tobacco use. Denies illicit drug use.

            Wine 1x/month. Traveled to UK, Caribbean in last 3 months.

Review of Symptoms:  Constitutional: Pt denies fevers.

           Head: Headache, throbbing past 2 hrs, feels pulse in temple.

           Eyes:  Denies vision changes.

           ENMT- Denies cold/sinus symptoms

                                      

This focused assessment will assess his constitution, head, eyes, ENMT, and neuro to rule out secondary causes, such as increased intracranial pressure as evidenced by papilledema on a fundoscopic exam or neck stiffness related to meningitis. Examining his eyes for photophobia and discussing aura could lead to a migraine diagnosis. Ensuring his strength is equal and strong on both sides could rule out a stroke or intracranial hemorrhage. Verifying he has no fever or infection could rule out diseases from his recent travel, such as malaria and Dengue fever. A focused examination will uncover the pertinent headache features, exclude serious secondary causes, and lead to a diagnosis with a plan to manage symptoms and create an ongoing care plan (Chinthapalli et al., 2018).

References

Bickley, L.S. (2023). Bates’ guide to physical examination and history-taking, 13th ed. Revised. New York: Lippincott, Williams, & Wilkins. ISN-13:9781975210533

Chinthapalli, K., Logan, A., Raj, R., & Nirmalananthan, N. (2018). Assessment of acute headache in adults – what the general physician needs to know.  Clinical Medicine.  https://doi.org/10.7861/clinmedicine.18-5-422