see below
MM
Descriptions
Presents with c/o headache
Pain is a ‘4’ on a scale of 1-10
Scoliosis corrected with Charleston brace, broken toe
No cold/sinus symptoms
Eye exam 2 years ago
No medications, NKDA
No hospitalizations
No tobacco use, wine once monthly, no recreational drug use
Single, lives alone
Traveled to UK, Caribbean in past 3 months
Throbbing for past 2 hours, can feel pulse in temple
Sports-induced asthma
No fever, no changes in vision
Categories
Chief Complaint- throbbing headache
History of Present Illness-throbbing headache for the past 2 hours and rates the pain a
4/10 with a pulse in the temple area.
Past Medical History-scoliosis that was corrected with a Charleston brace, a broken
toe, sports-induced asthma, and denies medications or known drug allergies.
Personal and Social History- denies tobacco use or illicit drug use and admits to
alcohol use of wine once per month.Travel within the past three months to the UK
and Caribbean. Single and lives alone and the last eye exam was two years ago.
Review of Symptoms
Denies fever or vision changes or cold/sinus symptoms
Headache that is throbbing in nature and can feel a pulse in the temple area
At first the way the question is asked about comprehensive or focused I felt lead to a
focused exam. After reviewing the details presented, I need to know more information
and would like to establish a relationship and baseline with the patient.
Due to the unknown of information the exam is a comprehensive exam. Again, due to not
knowing if the patient and the need to establish a baseline. According to Bickley et al.,
2021, the comprehensive exam does more than assess body systems. The comprehensive
exam personalizes the knowledge about the patient and builds a relationship. The
comprehensive exam provides a basis for assessing the patient’s concerns and answering
any questions (Bickley et al., 2021).
Reference
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