• Based on the descriptive information, would this be a focused or comprehensive assessment and, if focused, what system or systems would you want to assess and why?


  • 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


  • Chief Complaint
  • History of Present Illness
  • Past Medical History
  • Personal and Social History
  • Review of Symptoms
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