Nursing

Review this week’s Learning Resources, and consider the insights they provide about the case study.
Consider what history would be necessary to collect from the patient in the case study you were assigned.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

ANSWER

Patient Information

Initials: JM

Age: 20

Sex: Male

Race: Caucasian

S.

CC (chief complaint): The patient is complaining of intermittent headache.

HPI: 20-year old Caucasian male complains of an intermittent headache. The patient stated that the headache begun approximately three weeks ago. He describes the pain as diffuse pain but has a high intensity around jaw, cheekbones, noses and above the eyes.

Location: Jaw, cheekbones, nose, above eyes and head (diffuse).

Onset: 3 weeks

Character: throbbing/aching

Associated signs and symptoms: The patient admits that he has been under a lot of stress for the past few weeks at college and work

Timing: The patient experiences pain at different times throughout the day.

Exacerbating/ relieving factors: No exacerbating elements. Patient reported of taking Ibuprofen to assist him with relieving pain.

Severity: Currently 0/10 but 7/10 at its greatest intensity.

Current Medications: Ibuprofen PRN 400gm PO Q 6 hours as required to relieve pain.

Allergies: Patient has reported no known drug allergies.

PMHx: The patient’s immunizations are up to date. There is no past medical history. The Last Tetanus shot was on 7/2018.
Soc Hx: The 20 year old male patient is a college student who has currently majored in Political science. The patient works part time at a local restaurant. He is single and lives with his parents and has an active lifestyle. The patient denies of any drug abuse, illicit drugs, use of tobacco or alcohol. The patient is sexually active and relies on condoms for protection.

Fam Hx: The mother is living with kidney stones while the father is living with hypertension and coronary artery disease. The patient has a younger brother who has reports no medical issues. The paternal grandparents were involved in an accident while at a young age which lead to their deaths. Unfortunately, the patient is unsure of their medical problems. On the other hand, the maternal grandfather died in a house fire at the age of 60 but was living with coronary artery disease and hypertension while the maternal mother is living with hypertension and kidney disease.

ROS:

GENERAL:  No fever, weakness or chills. The patient does not record any weight loss.

HEENT: Eyes: No visual problem or loss, double vision, blurred vision or any yellow sclerae.

SKIN: The patient dies any itching. No body rashes.

CARDIOVASCULAR: The patient denies of any pressure, chest pain or discomfort. No peripheral edema or palpitations noted.

RESPIRATORY: Denies of any sputum, shortness of breath or cough.

GASTROINTESTINAL: The patient denies of any nausea, anorexia, diarrhea, constipation. No abdominal pains reported.

GENITOURINARY: The patient denies of any pain, difficulty or burning on urination.

NEUROLOGICAL: No syncope, ataxia, dizziness, numbness, paralysis or tingling in the extremities. The patient has complained of much pain around the jaws, cheekbones, nose and above the eyes. The patient also reports of diffuse headache for the past three weeks.  However, no changes in bladder control or bowel.

MUSCULOSKELETAL: The patient denies of any stiffness or pain to back, joints or neck.

HEMATOLOGIC:  There are no signs of anemia, no bruising or bleeding noted.

LYMPHATICS:  There is no history of splenectomy or enlarged nodes.

PSYCHIATRIC:  The patient denies of any suicidal thoughts. There is no history of anxiety or depression.

ENDOCRINOLOGIC: There are no reports of cold, sweating or hot temperature intolerance. No polydipsia or polyuria.

ALLERGIES:  There is no history of asthma, allergies or rhinitis notes.

O.

Physical exam: Generally, the patient appears to be well groomed, in good health and well nourished. The patient does not show any signs of distress. The skin is intact, dry and warm with no signs of diaphoresis.

HEENT: The head, eyes, ears, nose and throat are appearing normal. No hearing loss, rhinorrhea or swallowing issues reported.

Cardiovascular: regular rate, normal S1, no rubs, S2 heart sounds noted, no murmurs and gallops.

Respiratory: The respiratory rate is regular while the lungs are flawless to auscultation.

Gastrointestinal: No tenderness or abdominal pain. There are bowel sounds in all the four quadrants.

Neurological: Oriented, alter with no deficits noted.

Musculoskeletal: Normal motion in all joints with no reports of weakness.

Lymphatic: Non-tender, no swelling seen on lymph nodes

Hematological: No signs of petechiae or bruising.

Psychiatric: The patient does not show any symptoms of anxiety or depression.

Endocrinologic: No rhinorrhea or seasonal allergies.

Diagnostic results:

MRI: MRI can be used to detect brain tumors, the cause of headache, stroke, traumatic brain injury and development anomalies.

Erythrocyte sedimentation rate: This is a blood test that can be used to indicate inflammatory activity in the body. This will help monitor the development of an inflammatory disease.

Blood cultures: Blood cultures are essential in detecting blood infection such as fungi or bacteria. Blood culture is an essential test for patients with headaches with or without fever.

A.

Differential Diagnoses

Temporal arteritis: Temporal arteritis happens as a result of damaged or inflamed blood to the brain or head (Nesher, 2014). The symptoms of temporal arteritis include jaw pain, headaches, fatigue, vision loss and fever. The patient’s symptoms are similar to the stated symptoms for Temporal arteritis.

Migraine: A migraine headache can result to severe throbbing pain on one side of the headache, accompanied by vomiting, nausea and light sensitivity (Jürgens, Schulte and May, 2014). Considerably, migraine is a neurological condition that can reveal multiple symptoms. The symptoms indicated fit the patient in the category of migraine.

Brain Tumor: The general symptoms and signs of brain tumor include changes in the patterns of headache and a headache that is more sever and frequent (Joseph, Singh, and Manikandan, 2014). Brain tumor is probable diagnosis for the patient since headaches occur due to obstruction of cerebral spinal fluid flow.

Meningitis: Symptoms of meningitis include severe headache and pain in the back, muscle and neck, fatigue, fever and chills as well as vomiting and nausea (Knight and Glennie, 2010). The symptoms that the patient is presenting are similar to those of meningitis except for vomiting, fever and chills.

References

Joseph, R. P., Singh, C. S., & Manikandan, M. (2014). Brain tumor MRI image segmentation and detection in image processing. International Journal of Research in Engineering and Technology, 3(1), 1-5.

Jürgens, T. P., Schulte, L. H., & May, A. (2014). Migraine trait symptoms in migraine with and without aura. Neurology, 82(16), 1416-1424.

Knight, C., & Glennie, L. (2010). Early recognition of meningitis and septicaemia. The J Family Health Care, 20, 6.

Nesher, G. (2014). The diagnosis and classification of giant cell arteritis. Journal of autoimmunity, 48, 73-75.