For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases.
| Case 3 | |||
| Chief Complaint (CC) |
“I have been having frequents headaches lately” | ||
| History of Present Illness (HPI) | A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile. | ||
| PMH | Frequent headaches since I was 15, with menses. | ||
| Drug Hx | Ibuprofen for Headaches | ||
| Subjective |
Light makes headache worst Nausea associated with headaches. No vomiting, Headaches improve usually with rest, ibuprofen, and sleep, but it is annoying to have to sleep all-day | ||
| Objective Data | |||
|---|---|---|---|
| VS | B/P 108/64; Pulse 86; RR 16; Temp 98.6; | ||
| General | 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room | ||
| HEENT | no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal vision | ||
| Lungs | CTA AP&L | ||
| Card | S1S2 without rub or gallop | ||
| Abd |
benign, normoactive bowel sounds x 4; |
||
| Rectal exam | Non contributory | ||
| Integument | intact without lesions masses or rashes. | ||
| Neuro | Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout. Functional neurological exam is WNL |
Answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
- What teachings will you provide?
Submission Instructions:
- Your initial post should be at least 550 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
- You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
- All replies must be constructive and use literature where possible.
