Approach To Patients Presenting With Headache

Approach To Patients Presenting With HeadacheHeadache is one of the common presenting complaints in a physcians office. It is important to identify which headaches are benign, needing no intervention and which requires action. Following questions needs to be asked in history:

Clinical History

1. Does the patient have >1 type of headache?

2. Time:When did the headache start? New or recently changed headache calls for especially careful assessment. How often do they happen? Do they have any patteren( e.g constant,episodic,daily). How long do they last? Why is the patient coming to the doctor now?

3. Character: Nature and quality, site and spread of the pain. Associated symptoms e.g nausea/vomiting, visual disturbance, photophobia, neurological symptoms.

4. Cause: Ask about predisposing and /or trigger factors; aggrravating snd /or relieving factors; family history of similar headaches.

5. Response:Details of medication used (type, dose, frequency, timing). What does the pateint do? e.g can the patient continue work?

6. Health between attacks: Do the headaches go completely or does the patient feel unwell between attacks?

7. Anxieties and concerens of the patient

Physical Examination

In acute seveer headache, examine for purpuric skin rash. In all cases check BP, brief neurological examination including fundi, visual acuity and gait, palpation of temporal regions/ sinuses for tenderness and examination of neck. In young children measure head circumference and plot on centile chart.

Red Flags To Take Immediate Action

Clinical Features Of Patients Presenting With Angina

Angina PectorisAngina is defined as a condition in which patient suffers from chest pain due to decreased blood supply to the cardiac muscles. Most common cause is obstruction or spasm of coronary arteries.

Clinical Presentation

Diagnosis is usually made on clinical history. Patients with stable angina present with:

Pain:

Episodic central-crushing or band like chest pain that may radiate to jaw/ neck or one/both arms. Pain in the arm/ neck may be the only symptom. It is important to ask about the frequency, severity, duration and timings of the pain.

Precipitating/ Relieving Factors:

Angina pain is usually precipitated by exertion, cold, emotion, and/or heavy meals. Pain stops with rest or using glyceral trinitrate.

Associated Symptoms: 

May be associated with palpitations, sweating, nausea and /or breathlessness during attacks.

Presence of risk factors:

Patients who suffer from angina have certain risk factors like smoking, family history of cardiac disease, history of other vascular disease.

Physical examination

There are usually no physical signs although anemia may exacerbate symptoms. It is important to check BMI and BP. Look for murmurs especially ejection systolic murmur of aortic stenosis and any evidence of peripheral vascular disease and carotid bruits ( esp in diabetes).

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