Chief Complaint: Patient complaint of severe right sided head pain for the last 24 hours. Differential Diagnosis: Tension headaches, migraines, optic neuritis and intracranial hemorrhage. HPI: Mrs. L. A. is a 44 year old, Hispanic female who presents with a severe right-sided head pain for the last 24 hours, denies fever or head trauma. Additional subjective data crucial for the health care provider to obtain are; how did the headache begin? Have you had this type of headache before? How severe is your pain on a scale from 0 (no pain) to 10 (worst pain ever)? How does the headache feel? What aggravate and alleviate the headache? This information helps to evaluate onset, location, duration, character, and severity of the pain. A mental status screening, such as, Mini-Mental State Examination can be performed to evaluate mental status deficit to rule out a potentially serious or life-threatening situation for the patient requiring immediate testing (CT) and treatment (Dains, Baumann, & Scheibel, 2016). Intracranial hemorrhage (ICH) is a life threatening condition leading to stroke or coma. Symptoms includes sudden onset severe headache with or without trauma (Dains, et. al. 2016). Furthermore, to evaluate for migraines headaches or tension headaches the RNP should ask; are there any other …show more content…
Additionally, prescribed medications, OTC, and herbal therapy should be investigated. Health maintenance information such as physical exam, and vaccinations should also be assessed. FHX: Ask about any family history of tension headaches, migraines, optic neuritis, stroke, DM, HTN, CA, and CVD. Social History: Marital status? What does she do for a living? Does the patient drink alcohol or smoke? Does the patient do illicit drugs? Is the patient have any type of stress? How does the patient cope with
Patient states that she has had no head injuries, past or present. Patient states she has never suffered from vertigo or dizziness. BB states that she rarely suffers from generalized headaches. Patient avoids taking pain relievers of any kind when she does present with head pain.
The nurse could ask the client what they know about their condition, risk factors, and
Overall, Dr. Scharf’s report is quite concise. He documented the applicant’s current complaint as neck pain, radiating pain to both arms, and occasional headaches, as
Studies to be considered incorporate the accompanying [23], which are for the most part required by healing centers before they acknowledge patients for confirmation: Toxicology screening, especially for aspirin, acetaminophen, tricyclic antidepressants, and unlawful medications, pregnancy test in young ladies, quantitative drug or alcohol screening if the underlying toxicology screen is positive tests for general medical reasons for psychiatric conditions (eg, thyroid malady, incendiary inside illness, systemic lupus erythematosus, or Wilson
I began the interview with the patient by introducing myself and allowing her to do same, I then said to her whatever information she gave to me is strictly confidential between her and I and the nurses and doctors that would be taking care of her. My patient was a 60-year-old woman, who is an alcoholic that have drunk for the past thirty years of her life. As the interview progresses, I make sure that was listening attentively, had good body posture and eye contact to the
Patient is a 65-year-old right-handed white male who has been having trouble with sleep apnea. ENT is planning to do some septal surgery and in preparation for this, he had a CT of the sinuses. This revealed a possible right corona radiata lesion. He has had an MRI to better outline that lesion. It reveals within the mid right corona radiata there is an 8 x 9 mm dark T1 and T2 weighted nodule with slightly higher central signal and no enhancement. There is no evidence for vessel extending to this area. This area also blooms on several sequences and is dark on the gradient weighted sequences, suspicious for calcification or hemosiderin. Also, there is a posterior left nasopharynx, a lobulated
Third, mandatory health education and/or counseling classes as prescribed from licensed healthcare provider for specific diagnoses, if necessary.
Social Data-Ask the client who helps them during times of stress? What effects have your illnesses had on the family and are there any family problems affecting your illness? Do you have any religion or beliefs that could affect your health or recovery? Moreover, find out about the client’s education.
Introduction: Thunderclap headache (TCH), defined as a severe headache with acute-onset, is a well-known presentation of subarachnoid hemorrhage (SAH) and other intracranial pathologies involving the CNS.1 However, reversible cerebral vasoconstrictive syndrome (RCVS), defined by recurrent headaches (often TCHs) with or without focal deficits, and segmental vasoconstriction of the cerebral arteries, is a remarkably common yet under-recognized cause of TCH.1 While RCVS generally follows a benign course, RCVS may precipitate catastrophic complications including SAH and ischemic or hemorrhagic stroke in a minority of patients.2 This case aims to enhance the recognition of this relatively common, and potentially life-threatening, cause of TCH.
Just to clarify, you have decided not to go through with mediation because you are transferring to another facility and will not be working the medical provider who falsely accused of insubordination and verbal assault, are you also withdrawing your EEO complaint?
You may find yourself to be surprised when someone knows what they diagnosis or information may be when you attempt to relay information on them. If the patient and family have problems with accepting negative information of for whatever other reasoning, you may ask them, “What would you like to know.” And go from there. Just make sure as the caregiver to be extremely open and honest towards whatever you are going to say. Don’t say it rudely, and in an uncaring vocal tone.
Patient is a 26-year-old right-handed white female who presents with her husband for followup after a vertebral dissection and stroke. This is an individual who has a long history of migraines. They went away during her pregnancy. Her child is six months old. After pregnancy, they started to recur again. She had a migraine on August 1, 2015 that was very severe and included intractable nausea and vomiting. For this she went to Wentworth Douglass Hospital Express care, where she was treated with medication for the symptoms. She went home, but later that night noted that the symptoms worsened, and she started having some visual field problem. At the time, she was lying on the sofa
A migraine is a cause of recurring attacks of pain to one side of the head or two sides of the head, depending on the individual. The pain is described as moderate to a severe throbbing or pulsing (MedlinePlus, 2016). It is more common among females compared to males (MedlinePlus, 2016). TL explained that she has always been having migraines before, but over the last month, there has been an increase of episodes. She stated that she had a migraine on for 6 days, this is considered pretty bad. Over what she had stated and explained to me, all her activities and lifestyle are considered factors and triggers that contributed to her migraine.
A 37-year-old patient presenting with her 6th migraine in a 2-week period indicates that additional information regarding the patient’s chief complaint is needed. I would start my exam by sitting down with the patient to discuss the patient’s present illness in further detail. I would focus on subjective questions that allow for specific details related to the migraine while also observing the patient’s response. These questions would include: location, onset, frequency, and duration, setting, quality, quantity or severity, exacerbating and relieving factors and other associated manifestations (Bickley & Szilagyi, 2013).
This is a co-complainant for complaint control # 18-SC-20161227161334. Co-complainant's contact information is: Gary Hewitt (760) 214-0630 - 5001 Sun Crest Court, Oceanside CA. 92056. Mr. Hewitt is calling regarding his mother named Betty Hewitt DOB: 9/20/23. Mr. Hewitt is being added to this complaint, as the information provided is in addition to the information provided previously regarding an allegation of Scabies Outbreak.