The eye exam reveals clear sclera, conjunctiva without injection, and PERRLA. EOMs are intact. There is no AV nicking or papilledema. Optic disks have clear margins. Nasal mucosa is without erythema or drainage. There is no sinus tenderness to palpation. Cranial nerves II–XII are grossly intact.
Cardiac: Unremarkable.
Respiratory: Unremarkable.
Neurologic: The patient is alert and oriented. Thoughts are coherent and articulation is clear and appropriate. Sensation and proprioception are grossly intact, and the Romberg test is negative. Gait is steady. Brudzinski and Kernig signs are negative.
CRITICAL THINKING
1 What is the most likely differential diagnosis and why?___Migraine with aura___Migraine without aura___Cluster headache___Tension headache___Meningitis___Temporal arteritis___Psychogenic headache
2 Are there tools that can be used to help assess this headache? If so, name two.
3 Which diagnostic studies should be considered?___CT scan___MRI___CBC___CMP___Lipid panel
4 What is the plan of treatment?
5 Are any referrals or follow‐up needed?
6 Does the patient’s psychosocial history impact how she might be treated?
7 Is the patient’s blood pressure the cause or the result of her headache?
8 Would the treatment change if the patient were a smoker or on birth control pills?
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