NURSE 6512 Week 9 Case 1: Headaches, Answered, Complete solution

NURSE 6512 Week 9 Case 1: Headaches For this week’s discussion, I was assigned case #1. In this case, a 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. For this case, five differential diagnoses and necessary diagnostic testing needed to confirm the diagnosis will be discussed. S. Patient: T.I Sex: Male Age: 20 Race: Caucasian CC: Intermittent headaches HPI: Complaints regarding an intermittent headaches are received from a 20-year old Caucasian man. The headache mainly diffuses over the past 3 weeks. The headache occurs diffusely, but the greatest intensity is felt around the cheekbones, jaw, nose, and above the eyes. Location: head, above eyes, through nose, cheekbones, and jaw Onset: intermittent headaches over the past 3 weeks Character: dull at first and then intensifies to aching/throbbing Associated signs and symptoms: patient has been under a lot of stress the past few weeks with his job and college Timing: headaches occur at different times throughout the day / Exacerbating/ relieving factors: patient reports taking Ibuprofen to help with the pain Severity: 6/10 pain scale at its greatest intensity Current Medications: Ibuprofen 400 mg PO Q 6 hours as needed for pain Allergies: Patient reports No Known Drug Allergies PMHx: No significant past medical history, Immunizations are up to date. Last Tetanus shot was 7/2015 Soc Hx: Patient is a college study who is studying sports management and is also working a full time job. He enjoys playing and watching sports in his spare time, is single, and lives with his parents. He does not smoke any kind of tobacco products and does not drink alcohol. Patient reports wearing his seat belt every time he is in a motor vehicle. Patient has a cell phone but does not use it while driving. There are smoke detectors in his parent’s home. Family Hx: Mother is alive and has diabetes, Father is alive and has high blood pressure, and younger sister is alive and has no medical problems. Both sets of grandparents are deceased due to natural causes. ROS: GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. / CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: No burning on urination. NEUROLOGICAL: no dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. Vital Signs: Height is 5’10”, Weight is 146 pounds; Temp: 98.6, HR: 72, RR: 18, BP: 123/64, Spo2 100% on Room Air. Physical exam: / General: Well appearing, well-groomed and well nourished male in no obvious signs of distress: Skin: Skin is warm and dry, no diaphoresis HEENT: HEENT are normal appearing, no rhinorrhea, hearing loss, or swallowing difficulties Cardiovascular: normal S1, S2 heart sounds, regular rate, no chest pain; no rubs, gallops or murmurs. Respiratory: Lungs are clear to auscultation, respiratory rate is regular. Gastrointestinal: No abdominal pain or tenderness. + Bowel sounds in all 4 quadrants. Last BM: 1/23/18 Genitourinary: No difficulty voiding Neurological: Alert and oriented, no headache present at time of examination Musculoskeletal: range of motion in all joints are normal, no signs of weakness, equal strength in all 4 extremities. Hematological: no signs of bruising or petechiae Lymphatic: lymph nodes are non-edematous and non-tender Psychiatric: Patient exhibits no signs of depression or anxiety Endocrinologic: No seasonal allergies or rhinorrhea. Diagnostic results: / Necessary diagnostic tests that need to be performed on this patient to determine the appropriate diagnosis are: Complete Blood Count- A CBC can help to determine if the patient has any type of blood dyscrasias; headache can be a sign of anemia (Dains, Baumann & Scheibel, 2016, p. 229). Erythrocyte Sedimentation Rate- An ESR test can help determine if there is inflammation throughout the body an can signify temporal arteritis (Dains et al, 2016, p. 229). CT scan- This scan will h