SUBJECTIVE
CC: “I’ve had a headache for 3 weeks, and it’s still there.”
HPI: 40 year old single college Professor with complaints of daily headache for 3 weeks. She describes the headache as dull to pounding at times, from 3 to 8 on scale of 1-10 (10 being worst pain). The pain has not gotten worse, but has not gotten better either. She has no previous medical history or history of headaches or migraine headaches. Her head hurts “in the back of head and goes to the top”, and is occasionally associated with dizziness (lightheadedness, denies vertigo) and nausea (although has had no emesis). She denies photophobia, blurred vision, diplopia, tearing, rhinorrhea, numbness, or sensitivity to noise. She cannot relate any provocative or palliative …show more content…
Lymph nodes-denies enlargement or pain. Bones, joints, muscles- denies joint pain, swelling, stiffness, or weakness. Endocrine- denies polydipsia, polyuria, polyphagia, cold/heat intolerance, and no appetite or weight changes. Head normal. Eyes- above info, denies visual loss diplopia, redness or drainage. Ears- denies hearing changes, tinnitus, vertigo, drainage, or pain. Nose- denies discharge, inflammation, obstruction, or epistaxis. Mouth- denies sores, bleeding, and toothaches. Throat- denies sore throat, voice changes, and hoarseness. Neck- denies stiffness, swelling, or pain. Respiratory- denies SOB, cough, wheezing, pain. Cardiovascular- denies CP or tightness, palpitations, DOE, edema, claudication, or history of heart murmur. GI- denies N/V/diarrhea/ constipation, abdominal pain, change in bowel habits, bloody stools, or rectal pain. Genitourinary- denies dysuria, hematuria, and pain. Menstrual- denies dysmenorrhea, previous pregnancies, sexual activity, or previous venereal diseases. Last Menstrual Period 2 weeks before this visit. Neurologic- denies smell changes, taste changes, hearing, and speech changes; swallow difficulty, weakness, paralysis, tremors, seizures, paresthesia, or confusion. She has been sleeping “a lot”, goes to bed at 12 am, and rises at 7 or 9 am, naps …show more content…
Visual fields full to confrontation. EOM’s full, no ptosis. PERRLA, optic discs sharp without papilledema, macula intact.
EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.
NOSE: No nasal discharge.
THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition.
NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.
LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
ABDOMEN: Positive bowel sounds. Soft, no distended, no tender. No guarding or rebound. No masses.
MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal
CC: “I’ve had a headache for 3 weeks, and it’s still there.”
HPI: 40 year old single college Professor with complaints of daily headache for 3 weeks. She describes the headache as dull to pounding at times, from 3 to 8 on scale of 1-10 (10 being worst pain). The pain has not gotten worse, but has not gotten better either. She has no previous medical history or history of headaches or migraine headaches. Her head hurts “in the back of head and goes to the top”, and is occasionally associated with dizziness (lightheadedness, denies vertigo) and nausea (although has had no emesis). She denies photophobia, blurred vision, diplopia, tearing, rhinorrhea, numbness, or sensitivity to noise. She cannot relate any provocative or palliative …show more content…
Lymph nodes-denies enlargement or pain. Bones, joints, muscles- denies joint pain, swelling, stiffness, or weakness. Endocrine- denies polydipsia, polyuria, polyphagia, cold/heat intolerance, and no appetite or weight changes. Head normal. Eyes- above info, denies visual loss diplopia, redness or drainage. Ears- denies hearing changes, tinnitus, vertigo, drainage, or pain. Nose- denies discharge, inflammation, obstruction, or epistaxis. Mouth- denies sores, bleeding, and toothaches. Throat- denies sore throat, voice changes, and hoarseness. Neck- denies stiffness, swelling, or pain. Respiratory- denies SOB, cough, wheezing, pain. Cardiovascular- denies CP or tightness, palpitations, DOE, edema, claudication, or history of heart murmur. GI- denies N/V/diarrhea/ constipation, abdominal pain, change in bowel habits, bloody stools, or rectal pain. Genitourinary- denies dysuria, hematuria, and pain. Menstrual- denies dysmenorrhea, previous pregnancies, sexual activity, or previous venereal diseases. Last Menstrual Period 2 weeks before this visit. Neurologic- denies smell changes, taste changes, hearing, and speech changes; swallow difficulty, weakness, paralysis, tremors, seizures, paresthesia, or confusion. She has been sleeping “a lot”, goes to bed at 12 am, and rises at 7 or 9 am, naps …show more content…
Visual fields full to confrontation. EOM’s full, no ptosis. PERRLA, optic discs sharp without papilledema, macula intact.
EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.
NOSE: No nasal discharge.
THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition.
NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.
LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
ABDOMEN: Positive bowel sounds. Soft, no distended, no tender. No guarding or rebound. No masses.
MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal