For this week’s discussion, I was assigned case #1. In this case, a 20-year-old male complains of
experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest
intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
For this case, five differential diagnoses and necessary diagnostic testing needed to confirm the
diagnosis will be discussed.
S.
Patient: T.I
Sex: Male
Age: 20
Race: Caucasian
CC: Intermittent headaches
HPI: Complaints regarding an intermittent headaches are received from a 20-year old Caucasian
man. The headache mainly diffuses over the past 3 weeks. The headache occurs diffusely, but
the greatest intensity is felt around the cheekbones, jaw, nose, and above the eyes.
Location: head, above eyes, through nose, cheekbones, and jaw
Onset: intermittent headaches over the past 3 weeks
Character: dull at first and then intensifies to aching/throbbing
Associated signs and symptoms: patient has been under a lot of stress the past few weeks with
his job and college
Timing: headaches occur at different times throughout the day
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, Exacerbating/ relieving factors: patient reports taking Ibuprofen to help with the pain
Severity: 6/10 pain scale at its greatest intensity
Current Medications: Ibuprofen 400 mg PO Q 6 hours as needed for pain
Allergies: Patient reports No Known Drug Allergies
PMHx: No significant past medical history, Immunizations are up to date. Last Tetanus shot was
7/2015
Soc Hx: Patient is a college study who is studying sports management and is also working a full
time job. He enjoys playing and watching sports in his spare time, is single, and lives with his
parents. He does not smoke any kind of tobacco products and does not drink alcohol. Patient
reports wearing his seat belt every time he is in a motor vehicle. Patient has a cell phone but
does not use it while driving. There are smoke detectors in his parent’s home.
Family Hx: Mother is alive and has diabetes, Father is alive and has high blood pressure, and
younger sister is alive and has no medical problems. Both sets of grandparents are deceased due
to natural causes.
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.
This study source was downloaded by 100000828511134 from CourseHero.com on 06-02-2022 16:09:35 GMT -05:00
https://www.coursehero.com/file/28583687/Week-9-Postdocx/
experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest
intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw.
For this case, five differential diagnoses and necessary diagnostic testing needed to confirm the
diagnosis will be discussed.
S.
Patient: T.I
Sex: Male
Age: 20
Race: Caucasian
CC: Intermittent headaches
HPI: Complaints regarding an intermittent headaches are received from a 20-year old Caucasian
man. The headache mainly diffuses over the past 3 weeks. The headache occurs diffusely, but
the greatest intensity is felt around the cheekbones, jaw, nose, and above the eyes.
Location: head, above eyes, through nose, cheekbones, and jaw
Onset: intermittent headaches over the past 3 weeks
Character: dull at first and then intensifies to aching/throbbing
Associated signs and symptoms: patient has been under a lot of stress the past few weeks with
his job and college
Timing: headaches occur at different times throughout the day
This study source was downloaded by 100000828511134 from CourseHero.com on 06-02-2022 16:09:35 GMT -05:00
https://www.coursehero.com/file/28583687/Week-9-Postdocx/
, Exacerbating/ relieving factors: patient reports taking Ibuprofen to help with the pain
Severity: 6/10 pain scale at its greatest intensity
Current Medications: Ibuprofen 400 mg PO Q 6 hours as needed for pain
Allergies: Patient reports No Known Drug Allergies
PMHx: No significant past medical history, Immunizations are up to date. Last Tetanus shot was
7/2015
Soc Hx: Patient is a college study who is studying sports management and is also working a full
time job. He enjoys playing and watching sports in his spare time, is single, and lives with his
parents. He does not smoke any kind of tobacco products and does not drink alcohol. Patient
reports wearing his seat belt every time he is in a motor vehicle. Patient has a cell phone but
does not use it while driving. There are smoke detectors in his parent’s home.
Family Hx: Mother is alive and has diabetes, Father is alive and has high blood pressure, and
younger sister is alive and has no medical problems. Both sets of grandparents are deceased due
to natural causes.
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.
This study source was downloaded by 100000828511134 from CourseHero.com on 06-02-2022 16:09:35 GMT -05:00
https://www.coursehero.com/file/28583687/Week-9-Postdocx/
