Headache
A
27year old white female, Jamie, comes to you with the complaint of a headache.
Her vitals are as follows:
B.P
- 120/70 mm of Hg, Temp - 98.6 F,
R.R - 19/min, H.R
- 80/min.
Simulated
encounter:
Knock
on the door:
"Good morning, Mrs. Jamie. My name is Dr. XYZ. How are you doing today? What brought you in today?"("Doc, I have a headache.")
"Can
you tell me a little bit more about your headache?"("Doc, my head
hurts so much.")
"How
long have you had your headache?"("For several hours.")
"How did the pain start? I mean, was it all of a sudden or gradual?"("It started suddenly.")
"Is
it a constant or intermittent type of pain?"("It’s pretty much
constant.")
"Can
you please show me
exactly where the pain is?"("All
over my forehead.")
"Does
it hurt anywhere else? Like your jaw or the back of your
neck?"("No.")
"What
were you doing before you noticed the headache?"("I was in my
office.")
"How do you describe your pain?"("It’s a band-like sensation.")
"On a scale of 1 to 10, which number would best describe your pain?"("I would say probably between 7-8.")
"Is there anything that relieves your pain?"("Yes, staying in a dark room.")
"Is there anything that makes it hurt more?"("Yes, bright light and moving around.")
"Have
you felt nauseated or been vomiting? ("I’ve been a little bit nauseated
but haven’t thrown up.).
"Have you ever had this type of pain before?"("Yes, a couple of
times about three months ago.")
"You said you’ve had headaches like this before. When you get these headaches, how long do they last? Do you have any warning before they come? I mean, is your vision blurry or do you see flashes?" (Ask the premonitory symptoms) ("No, I have no prior warning. They just hit me like a ton of bricks.")
"Do
you have any blurriness or double vision now?"("No.")
"Are these episodic headaches affecting your daily activities?"("No, I’m working as usual.")
ROS
(For CSA, review of systems is very focused):
Ok, let me quickly ask you some other questions:
"Do you have any fever?"("No") "chills?"("No")
"Is your neck stiff?"("No")
"Have your eyes been watering?"("No")
"Have you had a runny nose?"("No")
"Have you noticed any ear discharge?"("No")
"Have you had any head trauma?"("No")
"Have you had any weakness in your arms or legs?"("No")
"Have you noticed any sensory changes, like tingling or numbness in your hands or legs?"("No")
"Do
you have any problem with your bowel movements?"("No")
"Has
there been any change in your appetite?"("No")
"Have
you lost or gained weight lately?"("No")
"Do
you have any urinary complaints?"("No")
PMH:
"Do
you have any other medical problems?"("No")
"Do
you have a H/O high blood pressure?"("No")
"Have
you ever been hospitalized before?"("No")
All:
"Are
you allergic to anything?"("No")
Medications:
"Are
you taking any prescription or over the counter medications?"(" Yes,
Tylenol.")
"Have
you ever taken recreational drugs?"("No")
"Do
you use any hormonal contraception?"("No")
FH:
"Can you please tell me something about the health of your family members?"("They are fine.")
"Does anyone in the family have habitual headaches?"("Yes, actually my sister has migraines. She wanted me to see you. She thinks my headaches might be migraines, also. What do you think?") "Ms. Jamie, from what you’ve just told me there is a possibility that they might be migraine headaches. But, I need to ask a few more questions and then give you a physical examination. That will help me better determine what the problem is. Is that ok with you?"("Sure, doc.")
SH:
"What
do you do for a living? Where do you work?"
"Do
you feel any stress at work or home? Are
you stressed out about anything?"
"Do
you smoke?"("No")
"Have you ever smoked?"("No")
"Do
you drink alcohol? How much and how often?"
"Are
you sexually active? Are there any problems in your sexual life?"
Physical examination:
Listen
for bruit at neck.
Palpate
the head, neck, and shoulder regions
Check
temporal arteries in elderly patients
Examine
the spine and neck muscles
Functional
neurological examination including getting
up from a seated position without any support, walking on tiptoes and heels,
cranial nerve examination, fundoscopy and otoscopy, tandem gait,
Romberg
test; check for symmetry on motor, sensory, reflex and cerebellar (coordination)
tests.
|
Please Subscribe to view the full content |