neurology

HEADACHE MDM

Based on the patient's history and physical there is very low clinical suspicion for significant intracranial pathology. The headache was NOT sudden onset, NOT maximal at onset, there are NO neurologic findings, the patient does NOT have a fever, the patient does NOT have any jaw claudication, the patient does NOT endorse a clotting disorder, patient DENIES any trauma or eye pain and the headache is NOT associated with dizziness or ataxia. Will treatment the patient symptomatically and reassess.

HEADACHE MDM #2

XXXX who presents with Headache.  Most likely 2/2 tension headache, migraine, or headache of non-emergent etiology. No focal neurological symptoms. Neuro exam is benign. Pt is nontoxic. VSS.

Unlikely SAH: headache is non thunderclap. Headache is gradual, non-maximal at onset and similar to headaches in the past.

Unlikely Subdural/epidural hematoma: no history of trauma, no anticoagulation.

Unlikely Meningitis: afebrile, no meningismus,  mild photophobia.

Unlikely Temporal arteritis: pt < 60 years old.  no tenderness in temporal area

Unlikely Acute angle glaucoma: PERRL, no eye pain.

Unlikely Carbon Monoxide Poisoning: no other house members with similar symptoms.

Plan: Will give pain medication and reexamine

I had a discussion with the patient and we shared decision making regarding emergent CT of the head. Risks and benefits were reviewed and discussed and radiation exposure vs. diagnostic uncertainty were reviewed. Based on overall clinical presentation and diagnostic data, it was felt the risk of life-threatening or serious pathology was low. Clinical decision tools for imaging were considered. Importance of strict follow up was stressed. The patient was warned to return to the ED with worsening or recurrent pain, neurologic symptoms, vomiting, altered mentation or if their condition worsened in any way.

Patient is alert, attentive, and oriented. Speech is clear and fluent. PERRL and there is no facial droop. There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally. SILT in all four extremities. Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. Gait is steady with normal steps.

Please follow up with Neurology in the next 1-2 days as an outpatient. Please continue taking your medications as prescribed. Do not drive until you are cleared by the Neurologist. If your seizures are not well controlled, avoid high-risk sports such as skiing and scuba diving. Avoid high-risk jobs that involve heavy or fast-moving equipment, heights, bodies of water, or other situations where you or others might be injured if you have a seizure. Avoid swimming. Return for worsening condition or any other emergencies.