MDM //

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. I do not suspect subarachnoid hemorrhage or intracranial hemorrhage because the patient denies a sudden onset, thunderclap-type, unrelenting headache. I do not suspect epidural hematoma because there was no trauma. I do not suspect meningitis because there is no fever or rash, no photophobia, and the neck is supple. I do not suspect temporal arteritis because that area is not tender to palpation, and the eye is not involved. I do not suspect glaucoma because the eye is not red and the pupils are responsive. I do not suspect sinusitis because there are no URI symptoms, and no sinus tenderness. I do not suspect treatable dental abscess or infection, as there is not tooth tenderness to percussion or gingival inflammation.



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