Abnormal findings are charted as a chain — finding, severity, comparison to baseline, the risk it creates, and the skilled action taken.
After a head strike on an anticoagulant, a new headache, vomiting, drowsiness, confusion, unequal pupils, or a focal deficit — concerning for a delayed intracranial bleed.
A sudden “worst-ever” or thunderclap headache — concerning for a subarachnoid hemorrhage or other emergency.
A new headache with fever and neck stiffness — concerning for meningitis.
Temporal-artery tenderness with jaw claudication and visual change in an older adult — concerning for giant-cell arteritis, which threatens vision.
A scalp wound with surrounding erythema, warmth, or purulence — concerning for infection.
A new scalp or skull mass, or a lesion that does not heal — requiring evaluation for malignancy.
A skull step-off, depression, or boggy swelling after trauma — concerning for fracture.
Shunt-tract swelling, redness, or signs of malfunction with headache, vomiting, or mentation change — concerning for shunt failure or infection.
