Chief Complaint : “I have been having frequents headaches lately History of Present Illness: A 25-year-old Hispanic

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

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Tiff week 7 Enhancing Compliance with USPSTF Preventive Screening Guidelines Tiffany Williams NU760-8H 4/5/2025 Problem Statement and Aim

Tiff week 7 Enhancing Compliance with USPSTF Preventive Screening Guidelines Tiffany Williams NU760-8H 4/5/2025 Problem Statement and Aim Statement Problem Statement: Inconsistent adherence to USPSTF guidelines for cardiovascular risk factor screenings in a primary care clinic. Leads to delayed diagnoses and preventable complications (e.g., stroke, heart attack). Aim Statement: Increase

Quality Improvement Project Hide Assignment Information Instructions Spring 2025 Leadership in Professional Nursing (NURS-… SD Assignments

Quality Improvement Project Hide Assignment Information Instructions Spring 2025 Leadership in Professional Nursing (NURS-… SD Assignments Quality Improvement Project The purpose of this assignment is to immerse the BSN student in an active quality improvement (QI) initiative on their assigned unit, critically analyze its implementation, and contribute meaningfully to its