MDM //

with history of chronic intermittent migraines, now presenting with similar constellation of symptoms without overt evidence and low suspicion for intracranial hemorrhage, subarachnoid hemorrhage, or CNS infection. Patient with non-focal neuro exam. Patient not immunocompromised and no family history of bleeding dyscrasias or aneursymal rupture. Headache gradual onset and similar to prior exacerbations. Will attempt pain control, serial neuro exams, and reassess. Patient presents with headache. No trauma. Not suspicious for epidural hematoma or subdural hematoma or skull fracture. Not on any blood thinners. Not acute onset, not suspicion for SAH. Afebrile, well appearing, non-focal neuro exam, not meningitis or encephalitis. Not altered. No eye pain, no vision loss, not suspicion for glaucoma. No jaw claudication, no amaurosis fugax symptoms, not suspicion for giant cell arteritis. No history of hypercoag, no suspicion for cavernous sinus thrombosis. Not stroke. Not seizure. No signs of elev ICP. Patient may have a migraine vs tension vs cluster headache. The patient was treated with XXX On reassessment, the patient denies any headache. All symptoms have resolved.



[Back to Main Menu]