I’m working on a nursing question and need a sample draft to help me learn.
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
Vitals: 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
Cardio: S1S2 without rub or gallop
Abdomin: benign, normoactive bowel sounds x 4;
Integument: Intacts without lesion masses or rashes
Neuro: Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
- What teachings will you provide?
Should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
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