HISTORY:
for
Onset: , following
Location: , on the
Severity: , / 10
Type:
Pattern: , worse during the
Worsening factors:
Treatments tried: ,
Analgesics use: days per month
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Neck:
Heart: ,
Lungs: ,
Cervical spine: on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- CT scan of the head
- MRI of the head
- Blood work: , , ,
-
-
-
- Regular exercise
- Stress management techniques
- Sleep hygiene
- Avoidance of triggers (e.g. caffeine, alcohol, stress)
- Referral to neurologist
- Referral to psychologist
- Follow-up in
- Return if headaches worsen, if new symptoms develop such as vision changes or weakness, or if symptoms do not improve with treatment