Nu610U4peerresonse1
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?
According to Bickley, (2020), a comprehensive examination is a basic “head-to-toe-examination†that functions as a source of fundamental and personalized knowledge about the patient that strengthens the clinician–patient relationship. For the focused examination, you will select the methods relevant to a thorough assessment of the targeted problem (Bickley, 2020). This patient is presenting with a chief complain (cc) of headache and therefore a focused assessment would be required. Systems that should be assessed for this patient include obviously head to assess for any history of dizziness, or injury that have caused the headache. The eyes and neck should also be assessed. The cardiovascular system could be a causative factor as head could be linked to hypertension. The provider would also assess neuro to assess for headache, dizziness, lightheadedness, fainting, seizures, tremors, memory problems
Categories
- Chief Complaint
- History of Present Illness
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- Pain is a ‘4’ on a scale of 1-10
- Throbbing for past 2 hours, can feel pulse in temple
- No fever, no changes in vision
- Past Medical History
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- Scoliosis corrected with Charleston brace, broken toe
- Sports-induced asthma
- No hospitalizations
- No medications, NKDA?
- Eye exam 2 years ago
- Personal and Social History
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- No tobacco use, wine once monthly, no recreational drug use
- Single, lives alone
- Traveled to UK, Caribbean in past 3 months
- Review of Symptoms
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- No fever, no changes in vision
- No cold/sinus symptoms
- Throbbing for past 2 hours, can feel pulse in temple
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