Overview
Case 3
Chief Complaint | “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?