If the DD : Migrane , tension headache , .. etc - what should I write in the physical exam under each diagnosis?? - USMLE Forums
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Old 05-21-2013
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Default If the DD : Migrane , tension headache , .. etc - what should I write in the physical exam under each diagnosis??

If the DD : Migraine , tension headache , .. etc - what should I write in the physical exam under each diagnosis??
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Your physical exam findings depend on what you find during the exam. If you referring to what physical exam you would do? I would go with start with the head and neck, then do CN exam. Palpate head, sinuses, neck. Visual exam as well as ear exam. I would also do sensory exam in addition to motor for the facial muscles. Check for Neck ROM, as well as Kernig/Brudzinkin's to rule out/in meningitis.

In most cases your physical exam would be normal. The SP may tell you he/she has tenderness to palpation on the sinuses, so you could note that for a case of Sinusitis. If there are any motor/sensory abnormalities you could note that as well.
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Originally Posted by fhs08 View Post
Your physical exam findings depend on what you find during the exam. If you referring to what physical exam you would do? I would go with start with the head and neck, then do CN exam. Palpate head, sinuses, neck. Visual exam as well as ear exam. I would also do sensory exam in addition to motor for the facial muscles. Check for Neck ROM, as well as Kernig/Brudzinkin's to rule out/in meningitis.

In most cases your physical exam would be normal. The SP may tell you he/she has tenderness to palpation on the sinuses, so you could note that for a case of Sinusitis. If there are any motor/sensory abnormalities you could note that as well.
I mean if all the physical exam is normal - should I leave the space of physical exam under each diagnosis blank ?
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Originally Posted by dralan View Post
I mean if all the physical exam is normal - should I leave the space of physical exam under each diagnosis blank ?
NO.. you will describe each of the maneuvers you did that are pertinent to the diagnosis in hand... PE in cases of migraine most of the time will be normal... thats a fact that supports your diagnosis.

IN tension headache the patient can either say that when you are palpating a particular area he feels pain.. either that or he can contract some muscles so that they are stiff (goes perfectly fine with tension headache).. Or it can be normal.. again this supports the diagnosis of tension headache as well.

The fact that Nasal sinuses will be normal.. without pain ALSO supports the diagnosis of migraine and/or tension headache.. this is a perfect example of PERTINENT NEGATIVES that support a DIAGNOSIS.
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Originally Posted by dralan View Post
I mean if all the physical exam is normal - should I leave the space of physical exam under each diagnosis blank ?
Pertinent Negatives in patient note

Hope this helps. Personally, I did not mention pertinent negatives in my DDX but I did in the HPI. I just thought the whole idea of putting a DDX is that you want to find positive findings that would support it. Everyone has a different approach. Whichever works best for you.
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