A 28-year-old man presents to the urgent care center with a 48-hour complaint of headache and nausea.
Chief Complaint: A 28-year-old man presents to the urgent care center with a 48-hour complaint of headache and nausea. ROS- The headache is primarily frontal and occipital and associated with mild nausea. He has taken various over-the-counter analgesics without any improvement in his headache. The intensity of the headache has gradually increased since it began, prompting him to come here today because he can no longer tolerate it. The only other complaint is neck and shoulder tightness. No cold symptoms or sore throat. No history of medical illness or head trauma. Objective exam: T- 100.8, HR 100 and regular, BP 110/68, RR 20. He is awake and fully orientated and his mini-mental exam is normal, however, he feels he is taking too long to answer questions. Physical Exam: CN 2-12 intact except bilateral horizontal nystagmus, skin clear, Kernig sign, negative Brudzinski sign. Motor, sensory, and cerebellar exams are normal. DTR is hyperreflexic throughout, negative Babinski sign.
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