1
Running head: WEEK 1
NR 603 Week 1
: Advanced Clinical Diagnosis and Practice Across the Lifespan
Week 1: PBL Case Discussion: Neurologic Disorders Part Two
S (Subjective)
Name: Christopher D. Age: 15 years old Sex: Male Race: White Insurance: NA
CC: Presents with the chief complaint of headache. Christopher D states that headaches occur
one to two times a week and can last one to two days. He puts his hands on his temple and
describes headache as pulsing. He reports pain as 3 out of 5, and was not relieved with 200 mg
of Ibuprofen or Naproxen. No aura. He has been unable to continue whatever task he is working
on (schoolwork, sports etc) when the headaches occur. Sometimes they upset his stomach, but he
has never vomited. Sleep helps sometimes. The only thing that seems to work is distraction, so
he plays Minecraft. The light from the TV hurts his eyes. No trigger identified. He wears
contacts, last visit to eye doctor last month, prescription was updated and he states he sees well.
He can see the board at school without difficulty.
HPI: Christopher D is a 15-year-old boy who presents with his mother. Christopher D is sitting
on the exam table playing on his phone. He does not look up when you enter. His mother
Margaret rises from the chair to greet you. Christopher D looks up and smiles but returns to
looking at the phone until his mother asks him to put the phone away. Christopher D appears his
stated age and is well groomed. You pull up your exam stool in front of Christopher D to ask him
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WEEK 1
why he is here today. “I get headaches, sometimes they last for days. Mom says all the time I
spend on the computer and looking at my phone is causing them, but I don’t think so.”
Onset: How long have you had these recurrent headaches? Have your headaches been
recurrent? How old were you when this started?
Location: Is the pain unilateral, or bilateral? Can you show me what hurts when you
have headaches (frontal, lateral, global)?
Duration: How long does your migraines last? 2 hours? 72 hours?
Characteristics: Does your head aches have a gradual onset, or pulsate? Do you
describe the pain as throbbing, pulsating, squeezing, or some other sensation? Note if he
prefers a dark room.
Aggravating factors: Is there anything in particular that makes your headaches worse? Is
there a pattern? Do your headaches occur when playing the video game?
Relieving factors: Is there anything in particular that helps your headaches, or makes
them go away? Is there anything that you avoid to keep from having a headache?
Treatments/therapies: Do you take anything to make your headaches go away, or do you
have any “rituals” that helps?
Severity: On a scale of 0-10, 10 being “I just want to die it hurts so bad,” what is your
pain level when your headaches are at their worst? Do your headaches interfere with
daily activities? Are your migraines associated with vomiting, photophobia,
phonophobia, or vomiting?
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WEEK 1
PMHx: Christopher’s mother reports his overall health as good. Have you been diagnosed
with immune deficiency, a malignancy, coagulopathy, or had any head trauma? As far as you
know, have you, or anyone in your immediate family had any cardiac related diseases,
particularly right to left shunt? Do you have a history of hypertension?
Childhood/previous illnesses: None
Chronic illnesses: None
Surgeries: None
Hospitalizations: One urgent care visit three months ago for a mild concussion sustained during
a tackle at the high school football game. No LOC at time of injury or after. No resulting
neurological deficits.
Immunizations: Childhood immunizations up-to-date. Receives the flu shot every year.
Allergies: Seasonal
Current medications: Are you taking, or have you taken any glucocorticoids? Are you
currently on any antidepressants? Are you taking any vitamins, or hormones? Do you take
medications to relieve your headaches frequently?
Blood transfusions: None
Social: Denies ETOH, tobacco, illicit drugs
Sleep: Sleeps 5 to 6 hours a night. States “I can’t fall asleep before 12:30 a.m. and I get up at 5
for football practice.”
Current medications: None
Running head: WEEK 1
NR 603 Week 1
: Advanced Clinical Diagnosis and Practice Across the Lifespan
Week 1: PBL Case Discussion: Neurologic Disorders Part Two
S (Subjective)
Name: Christopher D. Age: 15 years old Sex: Male Race: White Insurance: NA
CC: Presents with the chief complaint of headache. Christopher D states that headaches occur
one to two times a week and can last one to two days. He puts his hands on his temple and
describes headache as pulsing. He reports pain as 3 out of 5, and was not relieved with 200 mg
of Ibuprofen or Naproxen. No aura. He has been unable to continue whatever task he is working
on (schoolwork, sports etc) when the headaches occur. Sometimes they upset his stomach, but he
has never vomited. Sleep helps sometimes. The only thing that seems to work is distraction, so
he plays Minecraft. The light from the TV hurts his eyes. No trigger identified. He wears
contacts, last visit to eye doctor last month, prescription was updated and he states he sees well.
He can see the board at school without difficulty.
HPI: Christopher D is a 15-year-old boy who presents with his mother. Christopher D is sitting
on the exam table playing on his phone. He does not look up when you enter. His mother
Margaret rises from the chair to greet you. Christopher D looks up and smiles but returns to
looking at the phone until his mother asks him to put the phone away. Christopher D appears his
stated age and is well groomed. You pull up your exam stool in front of Christopher D to ask him
, 2
WEEK 1
why he is here today. “I get headaches, sometimes they last for days. Mom says all the time I
spend on the computer and looking at my phone is causing them, but I don’t think so.”
Onset: How long have you had these recurrent headaches? Have your headaches been
recurrent? How old were you when this started?
Location: Is the pain unilateral, or bilateral? Can you show me what hurts when you
have headaches (frontal, lateral, global)?
Duration: How long does your migraines last? 2 hours? 72 hours?
Characteristics: Does your head aches have a gradual onset, or pulsate? Do you
describe the pain as throbbing, pulsating, squeezing, or some other sensation? Note if he
prefers a dark room.
Aggravating factors: Is there anything in particular that makes your headaches worse? Is
there a pattern? Do your headaches occur when playing the video game?
Relieving factors: Is there anything in particular that helps your headaches, or makes
them go away? Is there anything that you avoid to keep from having a headache?
Treatments/therapies: Do you take anything to make your headaches go away, or do you
have any “rituals” that helps?
Severity: On a scale of 0-10, 10 being “I just want to die it hurts so bad,” what is your
pain level when your headaches are at their worst? Do your headaches interfere with
daily activities? Are your migraines associated with vomiting, photophobia,
phonophobia, or vomiting?
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WEEK 1
PMHx: Christopher’s mother reports his overall health as good. Have you been diagnosed
with immune deficiency, a malignancy, coagulopathy, or had any head trauma? As far as you
know, have you, or anyone in your immediate family had any cardiac related diseases,
particularly right to left shunt? Do you have a history of hypertension?
Childhood/previous illnesses: None
Chronic illnesses: None
Surgeries: None
Hospitalizations: One urgent care visit three months ago for a mild concussion sustained during
a tackle at the high school football game. No LOC at time of injury or after. No resulting
neurological deficits.
Immunizations: Childhood immunizations up-to-date. Receives the flu shot every year.
Allergies: Seasonal
Current medications: Are you taking, or have you taken any glucocorticoids? Are you
currently on any antidepressants? Are you taking any vitamins, or hormones? Do you take
medications to relieve your headaches frequently?
Blood transfusions: None
Social: Denies ETOH, tobacco, illicit drugs
Sleep: Sleeps 5 to 6 hours a night. States “I can’t fall asleep before 12:30 a.m. and I get up at 5
for football practice.”
Current medications: None
