Head ache

Welcome ,Introduce, rapport ,inquire  P/C 

Vitals , pain management  ---- if stable history

Interpreter, Appreciate

Patient centered nonjudgmental history focusing patient's ICE depending on DD , red flags-and other issues.Open ended aproach

My DD are -----RTI migraine,tension headache ,head injury,Hypertensive encephalopathy, SAH,ICH,Temporal arteritis,Sinositis ,Cluster headache,Meningitis,tumor,glaucoma,Drug withdrawal,Alcohol ,Refractive error, Dental, Depression ,epilepsy,TMJ, alcohol , cervical 

DDDAPSUN  

explore the presenting complain and back ground history 

Headache – Duration , Onset, Progression, What does he think, impact , severity ,location,bilateral or unilateral.

 radiation, aggravating and revealing factors, timing ,associated symptoms DOLTRARST, 

Ruleout DD one by one 

Does he have F/O upper or lower respiratory tract symptoms -cough, SOB,Throat pain,ear pain or discharge , tooth pain , pain o chowing 

sudden,onset progressive , thunder cap …a stiff neck, being sick, sensitivity to light, blurred seen  , seizures (fits) or loss of consciousness  5 S….. Associated nausea vomiting

 subarachnoid haemorrhage

 Migraine -UL, Throbbing UL,pulsating pain , N/V , flickering , Sound light sensitive , associated with trigger and activity  . in classical - tingling arm leg , flashing zigzag ,speech facial paralysis

Meningitis – 5 S and high fever, lethargy rash , behavior change (Encephalitis )

Tumor – early morning head ache ,vomiting, aggravate by sneezing coughing , Headache numb arm , Memory personality  , FNS,

Cluster - Tearing tearing stuffy red eye ,ptosis flashy face

Temporal arteritis - Throbbing tender temporal jaw , girdle pain ,lethargy , blur vision

Sinusitis – facial pain , dental pain , nasal stiff , discharge , loss smell , bad breath

Tension – continues ,evening , band ,scalp muscle tenderness , keep working ,stress

associated symptoms and systemic review 

Palpitation , chest pain , SOB

Epigastria pain , Back ache ,

Sleep mood water loose Vision  energy level

PMH- Migraine , HTN , DM HD Sinusitis , Drugs – CCB OCP Whether he is a regular patient or not

 FH- Brain tumor ,migraine , DM HD, stroke 

Contact history , Travel history 

AH-

Social – Smoking alcohol drugs ,occupation, Stress- mood suicidal ideas 

OE G/A, GCS, HT WT BMI,

 BP Pulse RR

      Pallor cyanosis  Dyspnea temperature ENT , LNE , Sinus , Teeth , Hydration ,temporal artery , scalp tenderness 

      Rash, Xan Facial asymmetry,drooping of eye, Neck Neck stiffness 

Thyroid , Cervical vertebra- palpate over C2 – C3 ,  Nicotine,  drug IV 

edema ,

Heart – Apex  ,HF  Pulse Bp Carotid bruit  

CHEST

ABD - HS

CNS – CN ( 2346 /57 ), UL , LL CNS examination including planter reflex  ----specially eye ( acuity field reactions, movements ,with Ophthalmoscope

thanks

 @ ECG shows LVH No other symptoms or signs -----HTN So rule out 2 ry causes

Going back to history , Examination , IX

Investigations- ECG , RBS , urine 

FBC , ESR , CRP , LP , Frontal X , Chest X ray , X ray spine

CTS or MRI at hospital-----LP?

AAAMEAR5 WWW KFCPOP CORN  CHOD SNAPS  

 Explanation and reassurance 

Sinusitis is an inflammation, or swelling, of the tissue lining the sinuses. Normally, sinuses are filled with air, but when sinuses become blocked and filled with fluid, germs (bacteria, viruses, and fungi) can grow and cause an infection. Amoxicillin , Mucolitics , Steam , Nasal decongesion , ENT refer - drain sinuses ----- orbital cellulitis cavernus sinus abcess  

Meningitis is an infection of the meninges (protective membranes) that surround the brain and spinal cord. The infection causes the meninges to become inflamed (swollen), which in some cases can damage the nerves and brain.

Migraine - is a severe, painful headache that is often preceded or accompanied by sensory warning signs such as flashes of light, blind spots, tingling in the arms and legs, nausea, vomiting, and increased sensitivity to light and sound. The excruciating pain that migraines bring can last for hours or even days.

Migraine -  like BA – Assess – mild – Aspirine 600 – 900 , maxalon , moderate – ergotamine 1mg + caffeine + maxalone , severe – ergotamine 1mg IM or sumitriptan 6mg SC                                                                                                                                           

Tension headache-  is pain or discomfort in the head, scalp, or neck, usually associated with muscle tightness in these areas. 

Massage hot bath , relaxation , yoga , meditation , counseling, CBT , Aspirin PCM Amitriptyline, diazepam  

Cervical problem -  X ray

Osteophytes , CX disk prolapse , osteosclerosis , erosion, Joint space widening

MX – CX color , Pain , Physio , Neck exercise , Hydrotherapy , trance electrical nerve therapy, swining , low dose TCA   ,

Deteriorating patient

Go to the patient and look how do you feel any discomfort? Input , UOP, Pain, vomiting  ?

G/A, Level of consousness  ( GCS) , Vitals  ( BP PULSE RR O2 T ), hydration , look for observation chart

Dillirium – When get hx what happen , Vitals ,cause for dillirium  pain , dehydration , infection , PE, alcohol withdrawal , rabdomyalosis ( CPK ) , constipation , urinary retention , problem with environment  unfamiliar , psychiatric , electrolyte imbalance , HF------- ECG and Blood IX …….PAID REC p for PE, A for alcohol , I for infection ,  d for drug/dehydration ,R –r for redo/ retention  , e for electrolyte and environment 

                  If agitated sedate with resperidone 0.5 mg  assess severity whether need to admit to ICU

Sudden deterioration – danger , response ( No response – CPR) , Seek for help ,

                               Air way – patent or not

                             breathing – rate air entry , trachea , muscle using , saturation  ,< 95% oxygen   

                            Circulation – BP Pulse capillary refill , Canula  and IVF ,

                           Disability and exposure  , examine and relevant investigations .

BP drop  after surgery – drs ABC 2 wide bore canula , fluid bolus N/S 1 L, catheter ,  blood for cross match , call to consultant , sent to hospital .

Chest pain – DRS If response mean airway + , AB (RR Regular trachea muscles ) C breaf history  LOTARDAR ST Worse pain             Risk assessment – PMH Dm S/A,    obese, FHX             

After surgery C/O abdominal pain – go , check for vitals , Hx EX , cause for pain ,Check charts , surgical note about pain management , which analgesic given , addicted , infection bleeding peritonitis, dehisions 

Prepare for a surgery – Premed , IX , Mentally stable , any worries , make sure drugs given

Procedure – NGT , Catheter , tube cannula

Anuria – fluid bolus , UOP hourly , SE, UEC