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Case Study: Chief Complaints

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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

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