A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk
A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
| Case 1 | Case 2 | Case 3 | |
| Chief Complaint (CC) | “It burns when I urinate” | “I had a severe headache yesterday with difficulty to speak” | “I have been having frequents headaches lately” |
| History of Present Illness (HPI) | A 68-year-old Caucasian male who reports to have increase on the frequency of urination with urgency for the last 5 days. He also present dysuria and nocturia. | A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk with last for about two hours. She did not seek medical attention. This morning she woke up with no problems but is here today due her husband advise. | A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile. |
| PMH | Benning prostatic hyperplasia diagnosed 3 years ago, UTI 6 months ago, Lithotripsy left kidney 10 years ago. No issues after treatment | Atrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin | Frequent headaches since I was 15, with menses. |
| Drug Hx | Rosuvastatin 20 mg Olmesartan 20 mg | Losartan 50 mg Xarelto 15 mg BID | Ibuprofen for Headaches |
| Subjective | Fever and chills, no changes in vision or hearing, no difficulty chewing or swallowing. No sexually active, nocturia, dysuria. Yellowish urethral secretion. | Feels Palpitations, joint pain with yesterday’s episode | 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 150/96; Pulse 89; RR 16; Temp 99.4; Ht 6,1; wt 180; | B/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%; | B/P 108/64; Pulse 86; RR 16; Temp 98.6; |
| General | well-developed male, no acute distress | well-developed female, no acute distress | 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room |
| HEENT | Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. | Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. | no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal vision |
| Lungs | CTA AP&L | CTA AP&L | CTA AP&L |
| Card | S1S2 without rub or gallop S4 present | Irregular heart beat with normal rate | S1S2 without rub or gallop |
| Abd | No tenderness normoactive bowel sounds x 4; | No tenderness normoactive bowel sounds x 4; | benign, normoactive bowel sounds x 4; |
| Rectal exam | Warm, swollen and painful prostate gland | Non contributory | Non contributory |
| Integument | good skin turgor noted, moist mucous membranes | intact without lesions masses or rashes. | intact without lesions masses or rashes. |
| Neuro | No obvious deformities, CN grossly intact II-XII | No obvious deficits and CN grossly intact II-XII | 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?
Submission Instructions:
- Your instructor will assign you your case number ( i have case # 3) and you will post on the case number you have been assigned.
- Your initial post should be at least 700 words, formatted and cited in current APA style with support from at least 2 academic sources.
Requirements: 700 words | .doc file
Grading Rubric
Your assignment will be graded according to the grading rubric.
| Discussion Rubric | |||||
| Criteria | Ratings | Points | |||
| Identification of Main Issues, Problems, and Concepts | Distinguished – 5 points Identify and demonstrate a sophisticated understanding of the issues, problems, and concepts. | Excellent – 4 points Identifies and demonstrate an accomplished understanding of most of issues, problems, and concepts. | Fair – 2 points Identifies and demonstrate an acceptable understanding of most of issues, problems, and concepts. | Poor – 1 point Identifies and demonstrate an unacceptable understanding of most of issues, problems, and concepts. | 5 points |
| Use of Citations, Writing Mechanics and APA Formatting Guidelines | Distinguished – 3 points Effectively uses the literature and other resources to inform their work. Exceptional use of citations and extended referencing. High level of APA precision and free of grammar and spelling errors. | Excellent – 2 points Effectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. Moderate level of APA precision and free of grammar and spelling errors. | Fair – 1 point Ineffectively uses the literature and other resources to inform their work. Moderate use of citations and extended referencing. APA style and writing mechanics need more precision and attention to detail. | Poor – 0 points Ineffectively uses the literature and other resources to inform their work. An unacceptable use of citations and extended referencing. APA style and writing mechanics need serious attention. | 3 points |
| Response to Posts of Peers | Distinguished – 2 points Student constructively responded to two other posts and either extended, expanded or provided a rebuttal to each. | Fair – 1 point Student constructively responded to one other post and either extended, expanded or provided a rebuttal. | Poor – 0 points Student provided no response to a peer’s post. | 2 points | |
| Total Points | 10 | ||||
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