Executive Solution Overview
– 2 years ago **files (1)** – ## Neurologicalmale.docx **## Neurologicalmale.docx** Chief Complaint **:**“I have been having frequents headaches lately History of Present Illness: A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile. PMH: Fr…
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– 2 years ago
**files (1)**
– ## Neurologicalmale.docx
**## Neurologicalmale.docx**
Chief Complaint
**:**“I have been having frequents headaches lately
History of Present Illness: 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
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
Cardiac: 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
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?**
500 words, APA style, 2 Academic Resources
**## Neurologicalmale.docx**
Chief Complaint
**:**“I have been having frequents headaches lately
History of Present Illness: 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
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
Cardiac: 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
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?**
500 words, APA style, 2 Academic Resources
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