Steps in Assessing a Non-Specific Headache

By Ryan Segovich

The following content is for informational purposes only. The content is not intended to substitute for professional medical training.

Throughout their careers, nurse practitioners treat patients with all sorts of medical issues. But there are a few patient complaints which come up more often than others. One of those is the complaint of a non-specific headache.

As with any ailment, there are a few assessment steps which are universal and some which are specific to the nature of the problem itself.

For a non-specific headache, the universal steps are part of the episodic assessment, while the specific steps are part of the physical examination.

Episodic Assessment

When meeting with any patient, it’s important to first introduce yourself and identify your role in the healthcare setting. Next, you’ll want to acknowledge the purpose of the exam (complete history and physical examination or episodic visit), and start asking the patient open-ended questions that can narrow down to more specific closed-ended ones. When asking questions, be sure to do so in an appropriate and professional manner.

 History of the present illness (HPI). 

Your questions should start out by addressing their chief complaint (CC) or history of the present illness (HPI). These questions can cover a number of details about the CC, including the onset, location, duration or timing, characteristics or severity, aggravating factors, relieving factors and treatment or medications implemented.

After gathering information, summarize it and repeat it back to the patient for clarification.

Past medical history (PMH)

Next, you’ll want to assess their past medical history (PMH). Questions to ask the patient include incidents of major childhood illnesses and sequelae, major adult illnesses, surgeries, hospitalizations, immunizations, allergies to medications or foods as well as the response and medications, including prescription, over the counter and herbal.

 Family and social histories

You’ll then want to ask about the patient’s family and social histories, as well as their personal habits.

For family history, ask the patient about both parents as well as siblings to see if there has been a history of the CC. Socially, you should ask about their marital history, children and employment history. And for habits, ask the patient about the use of tobacco, consumption of alcohol or use of illegal drugs.

System Review

Lastly, you should perform a review of systems with the patient. This includes asking about their general state of health, any issues with their head, eyes, ears, nose or throat, as well as problems with their respiratory, cardiac or gastrointestinal functions.

Episodic Physical Examination

Next, you’ll need to perform an episodic physical examination of the patient. This will give you a chance to more closely examine the patient and determine what, if any symptoms are present due to their non-specific headache.

You can start by making an overall general assessment of the patient’s mental status.

Next, you’ll want to check the patient’s head, eyes, ears, nose and throat. Specifically, inspect the head by taking note of any swelling and observing facial symmetry. You should then inspect the ears, nostrils, eyes and palpate for sinus tenderness.

Neck

You can then move down to the neck. Inspect the neck as well as palpate the lymph nodes and then auscultate the bilateral carotid pulse.

Cardiovascular and lung functions

After that, check the patient’s cardiovascular and lung functions. Start by inspecting the work of their breathing, symmetry of the action and the configuration of the thorax. Auscultate lung sounds in all anterior and posterior fields.

You should also auscultate all four heart valves.

Abdomen

Next, inspect the patient’s abdomen. You’ll check the gastrointestinal tract by auscultating for bowel sounds as well as palpating for tenderness and organomegaly.

 Neurological assessment 

You can then begin a neurological assessment of cranial nerves one through twelve. These include the olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, acoustic, glossopharyngeal, vagus, spinal accessary and hypoglossal.

Extremity sensory assessment 

Motor evaluation

A motor assessment will give you an indication of both the upper and lower extremities’ strength as well as the patient’s overall grip strength. An extremity sensory assessment for light sensations can also be performed at this time.

You should then assess the patient’s cerebellum and gait. Start by observing their normal walking and heel to toe walking. 

Check for Rhomberg and Pronator drift. Ask the patient to run the heel of each foot down the shin of the opposite leg. Check for smooth motion and firm placement of the heel against the shin.

Lastly, test for the Babinski reflex and the deep tendon reflexes of the patella, Achilles and brachioradiallis.

This completes the episodic physical examination of a patient with a non-specific headache. Upon completion, you’ll want to consider all that you learned from both the episodic assessment and physical examination to diagnose the cause of the symptoms.

Source:

blog.chamberlain.