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 to

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

This study source was downloaded by 100000760925736 from CourseHero.com on 03-24-2024 17:37:58 GMT -05:00

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., Soriano, R. P., & Bates, B. (2021). Bates’ guide
to physical examination and history taking. Wolters Kluwer.

This study source was downloaded by 100000760925736 from CourseHero.com on 03-24-2024 17:37:58 GMT -05:00

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