Neurological & Male Genitourinary Disorders
Take on the role of a clinician who is building a health history for the following case
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.
Primary Medical History- Frequent headaches since I was 15, with menses
Medication Use- Ibuprofen for Headaches
Subjective Data- 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
Cardio- S1S2 without rub or gallop
Abd- benign, normoactive bowel sounds x 4;
Rectal Exam- noncontributory
Integumentary- intact without lesions masses or rashes.
Neuro- Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL
- 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?