Nursing Question

Description

For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases: 

Case 3Chief 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.PMHFrequent headaches since I was 15, with menses. Drug HxIbuprofen for HeadachesSubjective

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-dayObjective 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 visionLungs
CTA AP&LCard
S1S2 without rub or gallopAbd

benign, normoactive bowel sounds x 4; 

Rectal
Non contributoryIntegument
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:

  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?

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