With regard to the case study<\/a> you were assigned:<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Review this week’s Learning Resources<\/a>, and consider the insights they provide about the case study.<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Consider what history would be necessary to collect from the patient in the case study you were assigned.<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Identify\u00a0at least five<\/strong>\u00a0possible conditions that may be considered in a differential diagnosis<\/a> for the patient.<\/p>\n Case Study 1: Headaches<\/strong><\/p>\n A 40 year old female presents with complaint of a headache for one week. Reports a \u201chead cold\u201d 3 weeks ago. \u00a0Thought it was getting better, but sinus symptoms<\/a> are back and even worse.<\/p>\n Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose<\/a>. Also feels mucus running down the back of throat. \u00a0Pain sometimes severe (8\/10) but with acetaminophen reduces to moderate (4\/10) and occasionally mild (2\/10). \u00a0Occasional nonproductive cough. \u00a0Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. \u00a0\u201cAcetaminophen improves my headache, but doesn\u2019t take it away.\u201d Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning \u2013 awakes with a headache. Ranges from 2\/10 at its best to 8\/10. Difficulty with concentrating at job and feels very tired.(Headache case study samples)<\/p>\n Patient Information:<\/a> A 36-year-old female(Headache case study samples)<\/p>\n S.<\/u><\/strong><\/p>\n CC: \u201c<\/strong>Constantly feeling tired even after a period of rest.\u201d<\/p>\n HPI: <\/strong>The patient present complains of persistent tiredness even after rest. The patient reports that she lacks energy every<\/a> day after a day\u2019s job, which began a few months ago but has progressively gotten worse. She reports missing several workdays due to a lack of energy even after showering and dressing for work. She reports sleeping more than eight hours a night while needing several naps throughout the day.\u00a0 She reports an uncomfortable buzzing sensation traveling from the neck down to the spine with what sounds to be a Lhermitte\u2019s sign. Uses interferon to manage MS, CBD oil to help with energy without relief, and Cetirizine 10 mg PO daily to manage allergies. (Headache case study samples)<\/p>\n Current Medications:<\/strong><\/p>\n Interferon to manage MS<\/p>\n CBD oil to help with energy without relief<\/p>\n Cetirizine 10 mg PO daily to manage allergies<\/p>\n Allergies: <\/strong>Nasal congestion.<\/p>\n PMx: <\/strong>Diagnosed with Multiple Sclerosis 3 years ago. Up to date with her pap smear. She goes for a monthly self-breast exam.\u00a0 Saw her dentist and eye doctor within the last year.<\/p>\n Soc Hx: <\/strong>Has a full-time job. Occasionally drinks wine during the weekend. Denies tobacco or illicit drug use.<\/p>\n Fam Hx:<\/strong> Married with two children. Her other has diabetes and has hypertension<\/a>. Farther and siblings are alive and well. She has an aunt diagnosed with MS and is wheelchair-bound.(Headache case study samples)<\/p>\n ROS<\/strong>:<\/p>\n GENERAL: Denies fever, chills, weight loss, or gain.<\/p>\n HEENT: Face symmetrical.\u00a0 PERRLA is normal. No retinal hemorrhages or exudates. Reports nasal congestion. Oral mucosa pink and moist<\/p>\n SKIN: Dry, warm, and intact<\/p>\n CARDIOVASCULAR: \u00a0Heart rate bradycardic. No chest pain<\/a>, chest pressure, or chest discomfort<\/p>\n RESPIRATORY: \u00a0Regular breath. No pauses or extra beats.<\/p>\n NEUROLOGICAL: \u00a0Reports nasal congestion. She denies loss of bowel or bladder.<\/p>\n MUSCULOSKELETAL: Normal muscle function.\u00a0Muscle tone palpated. No fasciculation, tenderness or atrophy.\u00a0 Buzzing sensation in the neck down the spine.<\/p>\n HEMATOLOGIC: Conjunctivae rim pale.<\/p>\n LYMPHATICS: \u00a0No lymphadenopathy.(Headache case study samples)<\/p>\n PSYCHIATRIC: \u00a0No depression or anxiety<\/a>. No history of splenectomy.<\/p>\n ENDOCRINOLOGIC: \u00a0No thyromegaly.<\/p>\n ALLERGIES: Nasal congestion.<\/p>\n Patient Information: <\/strong>A 35-year-old male(Headache case study samples)<\/p>\n S.<\/u><\/strong><\/p>\n CC: <\/strong>\u201cAcute low back pain.\u201d<\/p>\n HPI: <\/strong>The patient experienced an acute onset of low back pain radiating down the back of the left leg following yard work. The pain has worsened in intensity, and he is having difficulty bearing weight on the leg. The pain ease with Ibuprofen 800mg. Rates pain eight out of 10, described as sharp, lightening sensation. (Headache case study samples)<\/p>\n Current Medications: <\/strong><\/p>\n Ibuprofen 800 mg to manage the pain<\/a>.<\/p>\n PMx: <\/strong>Denies hospitalizations or surgical history. He sees primary care provider when he has an acute issue.<\/p>\n Soc Hx: <\/strong>Works for IT department from home. Sits about 8 hours per day.\u00a0 Reports smoking a pack<\/a> of cigarettes a day ten years but quit five years ago. Currently vapes daily.\u00a0 He reports one beer with dinner. Denies illicit drug use.(Headache case study samples)<\/p>\n Fam Hx: <\/strong>He recently divorced and shared custody of three children. Denies family history of the spine or musculoskeletal diseases or malignancy.<\/p>\n Health promotion:<\/strong> No regular health maintenance. Runs for at least 30 minutes daily. Eats healthy.<\/p>\n ROS<\/strong>:<\/p>\n GENERAL: Denies fever, chills, weight loss, or weight gain.<\/p>\n HEENT: \u00a0Eyes: \u00a0No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: \u00a0No hearing loss, sneezing, congestion, runny nose, or sore throat.<\/p>\n SKIN: No rashes or bruising.(Headache case study samples)<\/p>\n CARDIOVASCULAR: \u00a0No chest pain, chest pressure, or chest discomfort.<\/p>\n RESPIRATORY: \u00a0No shortness of breath, cough, or sputum.<\/p>\n GASTROINTESTINAL: \u00a0No anorexia, nausea, vomiting, or diarrhea.<\/p>\n NEUROLOGICAL: \u00a0Denies headaches, dizziness. Severe pain with active movement. Minimal pain with passive motion. Denies loss of bowel or bladder or saddle anesthesia.<\/p>\n MUSCULOSKELETAL: Denies history of lower<\/a> back pain or previous back injury.<\/p>\n HEMATOLOGIC: No anemia, bleeding, or bruising.(Headache case study samples)<\/p>\n LYMPHATICS: \u00a0No enlarged nodes. No history of splenectomy<\/p>\n PSYCHIATRIC: \u00a0No depression or anxiety<\/p>\n ENDOCRINOLOGIC: \u00a0ENDOCRINOLOGIC: \u00a0No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.<\/p>\n ALLERGIES: \u00a0No NKFDA<\/p>\n Patient Information: <\/strong>An 83-year-old female(Headache case study samples)<\/p>\n S.<\/u><\/strong><\/p>\n CC: <\/strong>\u201cA productive cough.\u201d<\/p>\n HPI: <\/strong>The patient presents a productive cough for the last three weeks. She reports fever on and off. She has chest pain, which worsens at night. She has a mild sore throat and nasal congestion.<\/p>\n Current Medications: <\/strong><\/p>\n Guaifenesin to relieve sore throat and nasal congestion.<\/p>\n Tylenol 500 mg PO daily to manage osteoarthritis.(Headache case study samples)<\/p>\n Citalopram 10 mg PO daily to manage depression<\/p>\n Omeprazole 10 mg PO daily to manage GERD<\/p>\n Levothyroxine 88 mcg PO daily to manage hypothyroidism<\/p>\n Allergies:<\/strong> Allergy to PCN with the reaction of hives.(Headache case study samples)<\/p>\n PMx: <\/strong>No history of asthma or any chronic lung diseases. <\/strong>Diagnosed with osteoarthritis. \u00a0Reports depression and GERD. Reports hypothyroidism. Hospitalized for the birth of three children. Had right knee replacement two years ago<\/p>\n Soc Hx: <\/strong>She lives in a retirement community<\/a> and uses a rolling walker for long-distance walking and a cane around the house. Denies recent travel. She denies smoking, alcohol, or illicit drug use.(Headache case study samples)<\/p>\n Fam Hx: <\/strong>Her children live close by and help her with errands.\u00a0 All her children are alive and well, no one with similar symptoms.<\/p>\n Health promotion: Up to date on vaccines, including flu and pneumonia vaccine. She wears her mask when she goes out in public and maintains a physical distance of six feet while practicing good hand hygiene.<\/p>\n ROS<\/strong>:<\/p>\n GENERAL: Reports fever.<\/p>\n HEENT: \u00a0Eyes: \u00a0No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: \u00a0Mucous membranes moist.\u00a0 No tonsillar exudate, oropharynx clear. Nares patent with clear drainage. Reports sore throat and nasal congestion.<\/p>\n SKIN: No rashes or bruising.(Headache case study samples)<\/p>\n CARDIOVASCULAR: \u00a0Reports chest pain and discomfort.<\/p>\n RESPIRATORY: \u00a0Reports excessive cough and occasional wheezing. Irregular heartbeats.<\/p>\n GASTROINTESTINAL: \u00a0Denies nausea, vomiting, or diarrhea.<\/p>\n NEUROLOGICAL: \u00a0No headache, dizziness, syncope, paralysis, ataxia, numbness. No change<\/a> in bowel or bladder control.<\/p>\n MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.<\/p>\n HEMATOLOGIC: No anemia, bleeding, or bruising.<\/p>\n LYMPHATICS: \u00a0No enlarged nodes. No history of splenectomy<\/p>\n PSYCHIATRIC: \u00a0Reports depression.(Headache case study samples)<\/p>\n ENDOCRINOLOGIC: \u00a0No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.<\/p>\n ALLERGIES: \u00a0No asthma.<\/p>\nHeadache case study samples-solution<\/h2>\n
CASE 1<\/strong><\/h2>\n
![\"Headache](\"https:\/\/nursingstudy.org\/examples\/wp-content\/uploads\/2023\/05\/download-2023-05-22T142803.607.jpg\")
<\/p>\nCASE 2<\/strong><\/h2>\n
CASE 3<\/strong><\/h2>\n
CASE 4<\/strong><\/h2>\n