XX, 20, Male
CC: ‚Äúintermittent headaches‚ÄĚ
HPI: 20 year old male who complains of experiencing intermittent headaches, which diffuses all over his head. The great intensity and pressure occurs above the eyes and spreads to the nose, cheekbones, and jaw.
Location: Generalized headache
Associated signs and symptoms: Greatest intensity above eyes and spreads to the nose, cheekbone, and jaw
Exacerbating/ relieving factors: Unknown
Current Medications: Unknown
Soc Hx: Unknown
Fam Hx: Unknown
- Mental Status Screen: The cause of a headache could have a life-threatening cause. Ruling out life threatening causes first is the priority. Completing a mental status screen ¬†first is imperative to ensure the patient is fully orientated and able to provide a accurate health history (Dains, Baumann, & Scheibel, 2016, p. 221).
- Determine the presence of a trauma. Bleeding can occur which can result in a sudden change in mental status (Dains, Baumann, & Scheibel, 2016, p. 223).
- Determine the presence of any underlying chronic disease process. Patients who are immunocompromised are more likely to acquire an infection that could affect the brain. Furthermore, a headache could result from an electrolyte imbalance, blood sugar change, or hypercapnia to name a few (Dains, Baumann, & Scheibel, 2016, p. 223).
- Complete blood count (CBC) with differential: Ordered to detect any abnormal lab findings (Dains, Baumann, & Scheibel, 2016, p. 229).
- Computed Tomography Scan (CT): Will detect any intracranial disease and should be completed with a new onset headache or in the presence of abnormal neurological findings (Dains, Baumann, & Scheibel, 2016, p. 229).
- Lumbar Puncture: Will evaluate the cerebrospinal fluid pressure and can detect altered components, such as lymphocytes, glucose, protein, and bacteria. Would aid in detecting an infection of the central nervous system (Dains, Baumann, & Scheibel, 2016, p. 229).
- Erythrocyte Sedimentation Rate (ESR): Elevated in the presence of inflammation and is utilized when arteritis is suspected (Dains, Baumann, & Scheibel, 2016, p. 229).
- Skull Radiography- Utilized post trauma to view intracranial structures (Dains, Baumann, & Scheibel, 2016, p. 229).
- Tension-Type Headache (TTH): Most common adulthood headache. Often related to muscle contraction that could be caused by hunger, depression, or stress. Sign and symptoms include bilateral, generalized, or localized pain that distributes in the frontotemporal region. The level of pain can be mild to moderate with a throbbing, tight, or pressurized pain with a gradual onset. Duration is different for every patient, but can range from hours to months (Dains, Baumann, & Scheibel, 2016, p. 230; Kim et al., 2017)
- Mixed Headache: Occurs from muscular and vascular contraction. The pain is often described as throbbing with a constant pain while the patient is awake. Further symptoms include tightness, pressure, and muscle contraction. This is a possible diagnosis, but not expected due to the patient not complaining of muscle contraction (Dains, Baumann, & Scheibel, 2016, p. 230).
- Sinusitis: Would be consider a secondary headache because it is caused by another disease process. Sore throat, postnasal discharge, and facial pain are often seen in conjunction with the headache. Specifically, pain occurs over the affected sinuses. This is a possible diagnosis, but additional respiratory symptoms would be expected if it were the cause (Dains, Baumann, & Scheibel, 2016, p. 230).
- Cluster headache: Onset is typically abrupt, occurs at night, and seen mostly in men. Pain is described as as severe, burning, piercing, or neuralgic. An episode can be 15 minutes to 2 hours at a time. The patient will experience several episodes in a cluster of time. Each cluster ranges from days to weeks. Other symptoms seen with a cluster headache are ipsilateral rhinorrhea, conjunctivitis, facial sweating, ptosis, and eyelid edema. Headaches are brought on by the consumption of alcohol, stress, and heat or wind exposure. Overall, the patients clinical presentation does not match cluster headaches (Dains, Baumann, & Scheibel, 2016, p. 230; Weaver-Agostoni, 2013).
- Dental disorders: The presence of a tooth abscess or nerve root dysfunction could cause a headache with associate facial pain. The oral inspection of the mouth may reveal redness or area of infection. The oral mucosa will also be tender to touch. This is a possible diagnose for out patient, but not likely given we do not know the results of his oral exam (Dains, Baumann, & Scheibel, 2016, p. 230).
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical
diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Kim, J., Cho, S., Kim, W., Yang, K. I., Yun, C., & Chu, M. K. (2017). Insomnia in tension-type
headache: A population-based study. The Journal Of Headache And Pain, 18(1), 95. doi:
Weaver-Agostoni, J. (2013). Cluster headache. American Family Physician, 88(2), 122-128.
XX, 47, F, Caucasian
CC ¬†¬†pain in R) wrist.
HPI: This is 47 year old white female who developed pain in her right wrist 2 weeks ago.¬† The pain causes her to drop her hairstyling tools.¬† She also has numbness and tingling in her right thumb, index and middle fingers.
Onset: two weeks ago
Associated signs and symptoms: numbness and tingling in the thumb and index and middle fingers
Timing: not shared
Exacerbating/ relieving factors: when working the pain in her wrist causes her to drop her hair-styling tools
Severity: not shared
Current Medications: not shared
Allergies: none shared
PMHx: not shared
Soc Hx: ¬†occupation of a cosmetologist
Fam Hx: not shared
ROS: Example of Complete ROS:
GENERAL: ¬†No weight loss, fever, chills, weakness or fatigue.
HEENT: ¬†Eyes: ¬†No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: ¬†No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: ¬†No rash or itching.
CARDIOVASCULAR: ¬†No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: ¬†No shortness of breath, cough or sputum.
GASTROINTESTINAL: ¬†No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: ¬†No burning on urination. Pregnancy not shared. Last menstrual period not shared
NEUROLOGICAL: ¬†No headache, dizziness, syncope, paralysis, ataxia. Numbness and tingling in the thumb, index and middle finger on the right extremity. No change in bowel or bladder control.
MUSCULOSKELETAL: ¬†No muscle, back pain or stiffness.¬† Has joint pain in the right wrist.
HEMATOLOGIC: ¬†No anemia, bleeding or bruising.
LYMPHATICS: ¬†No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: ¬†No history of depression or anxiety.
ENDOCRINOLOGIC: ¬†No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: ¬†No history of asthma, hives, eczema or rhinitis.
Physical exam: no information provided.
Diagnostic results: X-ray of wrist ‚Äď may reveal osteophytes, loss of joint space and fracture (Dains, Baumann & Scheibel, 2016).¬† ESR ‚Äď indicative of inflammation help in diagnosing arthriris (Dains, Baumann & Scheibel, 2016).¬† Nerve conduction studies confirm carpal tunnel syndrome by detecting median nerve entrapment (Wipperman & Goerl, 2016).
Carpal tunnel syndrome
Carpal tunnel syndrome will have patients presenting with weakness of the hand, dry skin over distribution of the medial nerve; history of repetitive movement, parathesia, weakness and clumsiness of affected hand (Dains, Baumann & Scheibel, 2016).¬† Cardinal symptoms of carpal tunnel will have patient presenting with pain and paresthesia in the distribution of the median nerve, this includes the thumb, index and middle finger; patients will have difficulty holding objects (Wipperman & Goerl, 2016).¬† ¬†The patient is presenting with the signs and symptoms that align with the description.
Wrist Fracture will have a patient presenting wit wrist pain that is worse with palpation; patient usually has history of a fall on an outstretched hand and will have pain and swelling of the wrist (Dains, Baumann & Scheibel, 2016).¬† Patients with a wrist fracture will present with pain, radial tenderness, swelling, wrist deformity, hematoma and decreased range of motion (Brants & IJsseldijk, 2015).
Fibromyalgia will have the patient presenting with trigger points on palpation that produce pain, general muscle and joint aches, occurring to those who have a history of depression, sleep disturbance and chronic fatigue (Dains, Baumann & Scheibel, 2016).¬† Patients with fibromyalgia will have tenderness upon palpation of pressure, and chronic pain disorders, widespread pain and no diagnostic tests available to diagnose (Horowitz, 2015).
Osteoarthritis will have patients who present with asymmetrical joint pain and stiffness that improves throughout the day, history of joint trauma and are obese; joints will be enlarged with limited range of motion (Dains, Baumann & Scheibel, 2016).¬† Osteoarthritis has patient‚Äôs complaints to be that of joint pain, pain that is disabling to them; this can cause neuropathy to the structure (POLAT, DOGAN, SEZGIN OZCAN, KOSEOGLU & KOCKER AKSLEIM, 2017).¬† Patients at an increased risk will have a history of repetitive weight lifting tasks, some form of joint trauma, are obese or have been diagnosed with diabetes mellitus (Dains, Baumann & Scheibel, 2016).
Tenosynovitis will have patients‚Äô present with pain with movement, swelling over the tendon, crepitus, and history of repetitive trauma of occupational activities, range of motion can be limited (Dains, Baumann & Scheibel, 2016).¬† ¬†Tenosynovitis commonly effects the forth extensor compartment and presents as a mass with wrist pain and limited range of motion (Ichihara et al., 2015).¬† Tenosynovitis can present when patients have other chronic medical diagnosis such as gout, rheumatoid arthritis, diabetes mellitus and hyperparathyroidism (Ichihara et al, 2015).
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Brants, A., & IJsseldijk, M. A. (2015). A pilot study to identify clinical predictors for wrist fractures in adult patients with acute wrist injury.¬†International Journal Of Emergency Medicine,¬†8(1), 1-5. doi:10.1186/s12245-015-0050-y
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Horowitz, S. (2015). Current Understanding of Fibromyalgia: Diagnosis, Treatment, and Theories About Causes.¬†Alternative & Complementary Therapies,¬†21(1), 25-31. doi:10.1089/act.2015.21101
Ichihara, S., Hidalgo-Diaz, J., Pruni√®res, G., Facca, S., Bodin, F., Boucher, S., & Liverneaux, P. (2015). Hyperparathyroidism-related Extensor tenosynovitis at the Wrist: a general review of the literature.¬†European Journal Of Orthopaedic Surgery & Traumatology,¬†25(5), 793-797. doi:10.1007/s00590-015-1596-3
POLAT, C. S., DOńěAN, A., SEZGńįN √ĖZCAN, D., K√ĖSEOńěLU, B. F., & KO√áER AKSELńįM, S. (2017). Is There a Possible Neuropathic Pain Component in Knee Osteoarthritis?.¬†Archives Of Rheumatology,¬†32(4), 333-338. doi:10.5606/ArchRheumatol.2017.6006
Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management.¬†American Family Physician,¬†94(12), 993-999.
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