Patient with Headaches: History and Actual physical Checks
A new. L.
“I have recently fallen from my bike and hit my head. I was wearing a helmet, but I still have headaches and cannot fall asleep for a long time when going to bed. ”
History of Present Illness
The patient has a complaint of persistent headaches, which started to occur after he fell from his bicycle. He fell and hit his head two weeks ago, and the pains began appearing a day after the accident. Thus, he has been having headaches for approximately two weeks. Moreover, the patient states that he cannot fall asleep due to headaches and struggles to get enough sleep to function properly. The headaches can occur during the day and get worse in the evening, since the patient works together computers and usually strains his sight, which can be an irritating factor. He really does not mention virtually any other possible signs. Relieving factors: A new. L. has constrained his time working together with the computer in addition to stopped biking regarding some time. They drinks green and even chamomile tea as being a natural remedy. They takes over-the-counter pain killers when the severe headaches are disturbing the sleep.
The person uses pain-relieving medications to package with headaches and even falls asleep. In any other case, he does certainly not mention any approved or over-the-counter medicines.
The patient has the mild type of allergic reaction to seafood. This individual does not statement having any medicine-related allergic reactions.
Past Medical History
Two years back, the patient chop down off his bicycle during a biking journey and strained their arm muscles because a result. This individual also had many accident-related neck traumas and was in the hospital to eliminate typically the possibility of some sort of concussion. A. M. was treated to the injuries and have physiotherapy for the arm. Physiotherapy persisted for three several weeks, when he looked like to recover most of his agility and strength.
History Surgical History
The sufferer has no background of major or even minor surgeries.
The particular patient’s great-grandparents’ wellness history is just not documented anywhere. As can end up being seen in Physique 1, A. T. ’s grandparents from your father’s side exceeded several years back. His grandmother exceeded away due in order to complications from the heart attack at the age of 84, and the particular grandfather died inside a car crash. Both grandma and grandpa failed to have any kind of hereditary conditions. The. L. ’s grandma and grandpa from your mother’s half remain alive, equally having hypertension and even mobility problems as a result of to retirement years. Typically the patient’s parents will be alive. The parent is a health-related worker with not any apparent medical concerns in addition to fatigue expected to a working work schedule. Typically the father can be an original construction worker using occupation-related allergies ~ he recently made an hypersensitive reaction to be able to dust together to be able to leave his work environment. Currently, they are doing work with his kid in the organization of selling athletic goods.
The sufferer likes biking and even often moves on riding a bike and hiking excursions with his pals. He leads a normal lifestyle, abstaining by drinking alcohol. Some sort of. L. does certainly not smoke or work with any illicit materials. He could be a smaller online retailer, offering bicycles and climbing equipment. Besides his / her active hobbies, he or she also loves to traveling. A. L. lifestyles alone within an apartment in the town.
Lovemaking and Reproductive Historical past
The sufferer is heterosexual. He could be at present single, his final long relationship ended two months ago, and he did not meet anyone else during this period. He has no children.
Health Care Maintenance (HCM) Strategies
The patient is interested in maintaining his health. He often visits doctors for regular check-ups, including dental care. Moreover, he frequently visits physiotherapists and massage therapists to check the condition of his muscles.
Review of Systems
The patient’s systems seem to be in great condition. There are no obvious reasons for the patient to have headaches. The physical assessment reveals no problems with the patient’s functioning.
Complete Physical Examination
Weight: 142 lbs.
BMI: 21. 6
Temp.: 97. 9 F
Mental Status Exam (MSE)
The patient shows up well-nourished and mown. A. L. is usually dressed up in clean outfits; his hair is usually well-kept. However, he or she appears to be somewhat fatigued. His behavior is definitely not erratic, in addition to he seems in order to be fully mindful of his area. He answers concerns with limited assemblage but in a new logical and logical way. His terminology is consistent, in addition to he communicates with no complications.
The patient is usually concerned about his / her headaches and wishes to receive therapy. Although he shows up tired, he don’t have any serious behaviour issues. His disposition is stable, and does not sole any dissatisfaction found in an aggressive or even distraught way.
You will have zero problem explaining his / her situation and states that he is not experiencing any acute pains during the examination. Perhaps, his stable condition allows him to formulate his thoughts clearly. The patient’s thought process seems to be logical, when he answers questions and supplies only necessary and even relevant information.
A. T. ’s responses are usually rather quick, yet he takes time to think over their answers and call to mind past events. This individual is conscious of their actions and terms and also knows about the dangers connected to his energetic hobbies. His conversation with the environment does not uncover any cognitive issues.
Typically the MSE does certainly not reveal any troubles with the patient’s state of mind (Matuszak, McVige, McPherson, Willer, & Leddy, 2016). They would not appear to be able to have any concerns with his way of thinking, communication, reaction moment, and actions. When he does certainly not have a pain at this found moment, his emotional state could possibly be firm at other instances a highly.
Your skin is definitely pink, warm, and even soft to feel. The patient has got tanned zones on the subject of his face, associated with the guitar, legs, and more affordable arms resulting from recurrent outdoor activities. You will discover no sunburns during these areas. The remainder of the skin area is paler throughout tone. The area of the skin area is smooth and even dry, especially inside the elbow region. The patient’s fingernails are pink and also have no deformations or even colored spots. The. L. ’s tresses is thick, darkish, short, and curly. It appears in order to be healthy plus well-nourished, with zero visible issues or even infestations. All associated with the signs show that the patient’s skin, hair, plus nails are healthful (Jarvis, 2015).
The mind is symmetrical without having any apparent traumas. The trauma how the patient had 2 weeks ago is certainly not present; there happen to be no spots or perhaps deformations. The ulterior auricular and occipital lymph nodes seem to be normal to accoster (Jarvis, 2015).
Your eye-sight is acute. Typically the eyes have white colored sclera. The pupillary light reflex involving the patient is definitely fast. The sufferer blinks to mild and responds to be able to motion. The cranial nerves (CN) II are normal. The particular pupils constrict in order to light and dilate appropriately. Eye motions are proportional to be able to any activities, Typically the CN III-IV and even VI are inspected. Eye closure is definitely standard; the CN VII is in one piece.
Typically the ears are shaped, their canals will be clear. The experiencing function can be regular, the particular CN VIII is usually intact, plus the affected person has passed the particular Whispered Voice Test out (Jarvis, 2015).
Nose in addition to Sinuses
The nose contains a normal color in addition to asymmetrical shape. The particular sinuses are very clear, and the manipuler will not reveal any kind of obstruction or sore sensation.
Throat and mouth
Your mouth is usually symmetrical. The lip area are somewhat dry out; the tongue is definitely pink, does not necessarily have any accidents, and has a new rough texture. The particular smell is regular. The CN IX and X are really intact as the affected person has passed the Motor Function Test (Jarvis, 2015).
The patient is able to move his head with no problems; there are no muscle pains during movement. The posterior cervical and superficial cervical lymph nodes are normal to palpation (Jarvis, 2015).
The patient’s breathing is regular and effortless. There are no obstructions in the respiration. The supraclavicular lymph nodes usually are normal.
Cardiovascular and Peripheral Vascular
The pulse level is nearby the reduced limit in the regular range, which may be described by the truth that the individual is the physically active guy and a semi-professional athlete. The patient’s BP seems regular, although they have the family history associated with hypertension. The stress measurement reveals simply no problems with BP.
The particular abdomen is smooth, non-tender. Normal intestinal sounds are provide in all of the four quadrants to auscultation. Back lymph nodes will be normal (Jarvis, 2015).
Typically the patient’s muscle activity is normal, though one arm is simply not as flexible as a result of previous injury. The neck and throat movements are standard, indicating no traumas from former injuries. and legs. Crossed-arm attractivity and resisted left arm extension reveal zero significant differences in addition to cause no discomfort (Malanga & Mautner, 2016).
The patient’s responses are of typical speed. The psychological functioning is steady, plus the patient is usually fully aware regarding the situation wonderful surroundings. The CN I-XII are unchanged (Jarvis, 2015). Your neurological system does not have problems.
Jarvis, C. (2015). Actual physical examination and well being assessment (7th ed. ). Philadelphia, PA: Elsevier Health Sciences.
Malanga, H. A., & Mautner, K. (2016). Musculoskeletal actual physical examination: An evidence-based approach (2nd ed. ). Philadelphia, PA: Elsevier Health Sciences.
Matuszak, L. M., McVige, L., McPherson, J., Willer, B., & Leddy, J. (2016). An acceptable concussion physical evaluation toolbox: Evidence-based actual physical examination for vol. Sporting activities Health , 8 (3), 260-269.