UST Neurological And Male Genitourinary Disorders Case Study
ANSWER
Subjective Data:
Additional subjective data that would be helpful to obtain includes:
- Pain Characterization: Ask the patient about the character, duration, and severity of their headaches. Inquire if the headaches are throbbing, stabbing, or any other specific description.
- Headache Triggers: Explore any potential triggers for the headaches, such as dietary factors, stress, or specific activities.
- Associated Symptoms: Ask if there are any associated symptoms with the headaches, like visual changes, aura, nausea, vomiting, sensitivity to light or sound, or neurological symptoms.
- Headache History: Inquire about the frequency and duration of the headaches over time, any patterns related to menstrual cycles or other factors, and any previous medical evaluations for the headaches.
- Medication Use: Ask about any other medications the patient is taking, including over-the-counter drugs and herbal supplements.
Objective Findings:
Additional objective findings to look for:
- Neurological Examination: Conduct a thorough neurological examination, including assessing cranial nerve functions, reflexes, sensory perception, and motor strength.
- Visual Field Testing: Perform visual field testing to check for any visual disturbances or field defects that might be associated with the headache.
- Ophthalmoscopic Examination: Examine the optic disc and retina to rule out any optic nerve abnormalities.
Diagnostic Exams:
Based on the information provided, the following diagnostic exams might be considered:
- Head CT or MRI: To assess for any structural abnormalities in the brain that could be causing the headaches.
- Electrocardiogram (ECG/EKG): To further evaluate the patient’s irregular heart rate and assess for any cardiac conditions contributing to the symptoms.
- Complete Blood Count (CBC): To check for signs of infection or other abnormalities that could be causing the patient’s symptoms.
Differential Diagnoses:
- Migraine Headache: Migraines often present with unilateral pulsatile headaches associated with nausea, vomiting, and sensitivity to light and sound. Hormonal triggers might also explain the patient’s history of headaches worsening with menses.
- Cluster Headache: Cluster headaches are characterized by severe unilateral pain around the eye or temple, often accompanied by autonomic symptoms like tearing and nasal congestion. The patient’s description of pain location and duration might suggest this.
- Transient Ischemic Attack (TIA): The patient’s age, sudden severe headache, and difficulty speaking could raise concern for a TIA, a temporary blockage of blood flow to the brain. This needs to be ruled out due to the potential for serious consequences.
Rationales:
- Migraine: The patient’s history of frequent headaches, sensitivity to light, and improvement with rest and sleep align with migraine characteristics.
- Cluster Headache: The description of a severe unilateral headache, along with the patient’s gender and age, might make cluster headache a consideration.
- Transient Ischemic Attack: The sudden severe headache and difficulty speaking could be indicative of a TIA, which requires prompt evaluation to rule out.
Teachings:
- Lifestyle Modifications: Teach the patient about potential triggers for their headaches, such as certain foods, stress, or lack of sleep, and provide guidance on managing these triggers.
- Medication Use: Discuss appropriate use of over-the-counter pain relievers, including potential side effects and risks of overuse.
- Seeking Medical Attention: Emphasize the importance of seeking immediate medical attention if the patient experiences sudden, severe headaches, neurological symptoms, or any changes in speech or vision.
Remember, these are just suggestions based on the provided case information. A thorough evaluation by a healthcare professional is necessary to make accurate diagnoses and treatment decisions.
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. Your instructor will assign you your case number. CASE #2
Case 1Case 2Case 3Chief 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.PMHBenning prostatic hyperplasia diagnosed 3 years ago, UTI 6 months ago, Lithotripsy left kidney 10 years ago. No issues after treatmentAtrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin Frequent headaches since I was 15, with menses. Drug HxRosuvastatin 20 mg
Olmesartan 20 mg
Losartan 50 mg
Xarelto 15 mg BID
Ibuprofen for HeadachesSubjective
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 episodeLight 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 VSB/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;
Generalwell-developed male, no acute distresswell-developed female, no acute distress25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room HEENTAtraumatic, 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 visionLungsCTA AP&L
CTA AP&L
CTA AP&LCardS1S2 without rub or gallop S4 presentIrregular heart beat with normal rateS1S2 without rub or gallopAbdNo tenderness normoactive bowel sounds x 4; No tenderness normoactive bowel sounds x 4;
benign, normoactive bowel sounds x 4;
Rectal examWarm, swollen and painful prostate glandNon contributoryNon contributoryIntegumentgood skin turgor noted, moist mucous membranesintact without lesions masses or rashes.intact without lesions masses or rashes.NeuroNo obvious deformities, CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XIICranial 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?
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