17 Aug I have been having frequents headaches lately”
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
Once you received your case number, 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?
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