Chief Complaint
: “I have been having frequents headaches lately
History of Present Illness: 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
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
Cardiac: 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
1.
What other subjective data would you obtain?
2.
What other objective findings would you look for?
3.
What diagnostic exams do you want to order?
4.
Name 3 differential diagnoses based on this patient presenting symptoms?
5.
Give rationales for your each differential diagnosis.
6.
What teachings will you provide?
500 words, APA style, 2 Academic Resources
