Take the following descriptive information and place it with the appropriate categories listed.
Chief Complaint: Presents with c/o headache
History of Present Illness: Pain is a ‘4’ on a scale of 1-10, Throbbing for past 2 hours, can
feel pulse in temple,
Past Medical History: Scoliosis corrected with Charleston brace, broken toe,
no medications, NKDA, No hospitalizations, Sports-induced asthma
Personal and Social History: No tobacco use, wine once monthly, no recreational drug use,
single, lives alone, Traveled to UK, Caribbean in past 3 months
Review of Symptoms: No cold/sinus symptoms, No fever, no changes in vision
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?
This is a focused patient assessment. It addresses a focused symptom that is restricted to a specific body system. The examination applied was relevant to the problem. A comprehensive patient assessment would have been appropriate for a new patient. The information given did not provide a baseline for future assessments. It also did not demonstrate the creation of a platform which would have allowed for health promotion through education and counseling (Bickley et al., 2021, p. 79).
A system to be included in this focused assessment would include neurologic. This could possibly be a migraine headache. First onset, location, duration, characteristics, associated factors and attempted treatments would be documented. Then certain red flags would be explored such as systemic illness noted by fever, neurologic signs, head trauma or progressive history. This case would prompt me to do a head, eyes, ears, nose and throat exam. Tenderness or swelling could allude to a sinus issue. The pain at the temples could be due to sinus pressure. A neurologic exam would be done to discover any other neurologic findings if there were findings like nuchal rigidity accompanying the headache to rule out meningitis or hypertension in the vital signs to rule out stroke (Steiner et al., 2019). There was travel, but it was over 3 months ago. Most headaches are benign, but the serious possibilities must be ruled out.