Makomed's Weblog

Acute Headache

Posted on: June 3, 2005

SUBJECTIVE: 19 y/o male PT comes in for HA x 2weeks qo day. Frequency has increased to qday. 2/10 pain localized to temples & forehead. Etiology unknown. No family hx of migraine, no past hx of trauma. Duration lasts for “hours & hours.” Complains of photophobia during onset. Increased pain during movement. Throbbing, constant pressure pain.

OBJECTIVE: No blurred vision. No distal nano deficit. NAD. VSS. HEENT unremarkable, except for mild edema in nose. Reflex 2+ sensation intact. Cerebellum intact.

ASSESSMENT: New Onset & Worsening Headache. Possibly Migraine? R/o Brain Lesion.

PLAN: Brain CT scan w/contrast. F/u.

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