MORNING

ENDORSEMENT
PRESENTED BY CLERK
MANDAL, PRATIKSHA
SHARMA, JITENDRA
 TABLE OF CONTENTS
ADMITTING
HISTORY
IMPRESSION
01 04
PHYSICAL DIFFERENTIAL
EXAMINATION DIAGNOSIS
02 05
SALIENT FEATURES THANK YOU
03 06
 01
ABOUT THE
PATIENT
 HISTORY

GENERAL DATA

P.V, a 27 years old Male, Filipino and Roman Catholic from

Bohol, is admitted at ACE Medical Center on February 14, 2024.

Informant and % Reliability: The Patient himself with 95%

reliability.
 HISTORY

CHIEF COMPLAINT

● Headache
 HISTORY
HISTORY OF PRESENT ILLNESS

● 1 week PTA, noted onset of gradual headache at frontal

area, throbbing, with PS 4/10, non radiating and
associated with dizziness . (-) fever, (-) blurring of vision,
(-) N/V, (-) body weakness, (-) chest pain, (-) dyspnea, (-)
cough. No consult was done. Patient self medicated with
paracetamol ( biogesic) 500 mg 1 tab for headache with
temporary relief.
 HISTORY

● 4 hour PTA, noted recurrence of headache at frontal area,

throbbing, with PS 10/10, non radiating and with
associated dizziness and numbness on right side of face.
(-) fever, (-) blurring of vision, (-) N/V, (-) body weakness, (-)
chest pain, (-) dyspnea, (-) cough. Persistence of symptoms
prompted admission.
 HISTORY
PAST MEDICAL HISTORY

● (-) Hypertension
● (-) Diabetes Mellitus
● (-) Bronchial Asthma
● Admitted due to tension headache ( Dec 11-14, 2023)
● Fatty liver
● No previous surgeries
● No known allergies to drug and medication
 HISTORY

FAMILY HISTORY

● (+) Hypertension- both sides from paternal and maternal

● (-)Diabetes Mellitus
● (-) Bronchial Asthma
● (-) Thyroid Diseases
● (-) Cancer
 HISTORY

PERSONAL AND SOCIAL HISTORY

● Non smoker
● Occasional alcoholic beverage drinker
● Denies illicit drug use
● Works as Operations Manager at IBEX
 REVIEW OF SYSTEMS
● Constitutional: (-) weight loss, (+) fatigue, (-) fever, (-) chills,
(-) night sweats, (-) anorexia.
● Skin: (-) rash, (-) pruritus.
● HEENT: (-) changes in vision and hearing, (-) naso aural
discharges, (-) oral ulcers, (-) gingival bleeding.
● Respiratory: (-)dyspnea, (-) cough, (-) hemoptysis.
● Cardiovascular: (-)chest pain, (-) palpitations, (-) edema.
● Gastrointestinal: (-) abdominal pain, (-) nausea, (-) vomiting,
(-) diarrhea, (-) dysphasia, (-) abdominal pain, (-)
constipation.
 REVIEW OF SYSTEMS

● Genitourinary: (-) dysuria, (-) urinary frequency, (-)

hematuria, (-) urinary urgency, (-) testicular pain/ swelling
● Endocrine: (-) polydipsia, (-) polyphagia, (-) diaphoresis.
● Musculoskeletal: (-) myalgia, (-) joint pain, (-) joint
swellings.
● Neurological: (+) headache, (-) syncope, (-) speech
problems, (-) memory loss, (+) numbness on right side of
face, (+) dizziness
 02
PHYSICAL
EXAMINATION
 PHYSICAL EXAMINATION
GENERAL: Awake, alert and Not in respiratory distress.

VITAL SIGNS: 140/100mmHg 36.4C 107bpm 22cpm

98% at room air

SKIN: No rashes or lesions. Warm to touch. Good turgor

HEENT: Anicteric sclerae, pinkish palpebral conjunctivae, no

alar flaring, Moist mucous membranes, (+) dental braces, No
cervical lymphadenopathy

CHEST & LUNGS: Equal chest expansion. Clear to auscultation

bilaterally. No accessory muscle use.
 PHYSICAL EXAMINATION
CARDIOVASCULAR: Tachycardic, Regular rate and rhythm. No
murmur. No JVD.

ABDOMEN: Flabby, NABS. Soft, non-tender and non-distended.

No palpable masses.

EXTREMITIES: No edema. Strong peripheral pulse. CRT < 2

secs
Neuro: awake, oriented to place, person and time, follows
commands
CN I: not assessed
CN II III: pupils reactive to light, 3mm in size both, isocoric
CN III, IV, VI: full range of extra ocular muscles
CN V: intact corneal reflex
CN VII: (+) facial asymmetry, right
CN VIII: intact gross hearing
CN IX X: intact gag reflex
CN XI XII: able to shrug shoulders and tongue at midline
Cerebellar: no intentional tremors
Muscle strength: RUE & LUE 5/5, RLE & LLE 5/5
(-) kernig’s sign, (-) Brudzinski’s signs
03 Salient features
(+) headache, throbbing pain

(+) dizziness

(+) Fatigue

(+) numbness on one side of

face
04ADMITTING IMPRESSION
MIGRAINE HEADACHE
05 DIFFERENTIAL DIAGNOSIS
 DIFFERENTIAL DIAGNOSIS
1. Hypertensive urgency

MOST LIKELY LEAST LIKELY

● High blood pressure
● Dizziness ● Chest pain
● Headache ● Dyspnea
● Fatigue ● Visual disturbance
● numbness on right side
of face.
 DIFFERENTIAL DIAGNOSIS
2. Meningitis

MOST LIKELY LEAST LIKELY

● Fever
● Severe Headache ● Neck pain
● Dizziness ● Vomiting
● Altered sensorium
● Fatigue
● (-) kernig’s sign,
● (-) Brudzinski’s
signs
 DIFFERENTIAL DIAGNOSIS
3. Sphenoid Sinusitis

LEAST LIKELY
MOST LIKELY
● Nasal discharge
● Headache ● Nasal Congestion
● Dizziness ● Fever
● Facial numbness ● Nausea & vomiting
THANKS!

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