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Case 3 | |
Chief Complaint | “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 |
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. |
Once you received your case number, answer the following questions:
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?
Submission Instructions:
