Assessing Neurological symptoms
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Case Study 1: Headaches
A 40-year-old female presents with complaint of a headache for one week. Reports a “head cold” 3 weeks ago. Thought it was getting better, but sinus symptoms are back and even worse.
Describes the headache is located across her forehead; feels like pressure behind my eyes and unable to breathe out of nose. Also feel mucus running down the back of my throat. Pain is sometimes severe (8/10) but with acetaminophen reduces to moderate (4/10) and occasionally mild (2/10). Occasional nonproductive cough. Feels feverish at times; noted frequent sneezing and no appetite. Bending over seems to make the headache worse. “Acetaminophen improves my headache but doesn’t take it away.” Taking Sudafed HCL 120 mg every 12 hours, with some relief. Symptoms are worse in the morning – awake with a headache. Ranges from 2/10 at its best to 8/10. Difficulty with concentrating at job and feels very tired.
To Prepare:
With regard to the case study you were assigned:
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.
- Case Study Assignment
- Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
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