NR 603 Week 1 Advanced Clinical Diagnosis and Practice Across the Lifespan

NR 603 Week 1 Advanced Clinical Diagnosis and Practice Across the Lifespan Week 1 Crystal Quince Chamberlain College of Nursing NR 603: Advanced Clinical Diagnosis and Practice Across the Lifespan October 2017 NR 603 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 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? 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 Social History: Good student. Lives with parents and older sister and younger brother Family History: Mother no health problems, father bipolar and well-controlled. Siblings in good health. MGM deceased from breast CA. MGF deceased: lung CA. PGM alive, 85, overall health good. Has Type 2 diabetes. Is there a family of neurological disorders (other than bipolar)? Is there a family history of headaches/migraines? Is there a family history of anxiety, borderline personality disorder, or depression? Is there a family history of hypertension? ROS: List any further questions you have for Christopher and link them to their respective differential diagnosis. General: Explain that if he feels a “thunderclap, or worse headache of his life” he must call EMS immediately (may be SDH). How often do you get headaches? Do you get migraines 2-4 times/month, or daily? How frequently do you get headaches? How long does your headaches last? Is there an aura associated with your headaches/migraines? Are your headaches concentrated on the same side of your body? Where do you typically get the pain associated with your headaches/migraines (sinuses, temporal area/ears, jaws, etc.)? Is there a particular time of the day that makes your headaches worse? Do your headaches keep you awake at night, or wake you up from sleep? Do your headaches wax and wane? Do you get headaches when you strain/Valsalva (ei: having a bowel movement)? Does light, noise, strenuous activities, or stress make your headaches worse? Does medications, dark rooms, quiet, cool compresses, or sleep make them go away? Do your headaches impair your ability to function in school? Do they stop you from going to school? Do your headaches keep you from participating in sports, activities, or hanging out with your friends? Have you noticed a change in your weight, or vision? Has your level of exercise, or sleep changed? How much sleep do you typically get in a 24-hour period? Has there been any recent changes at home, or school? Do you perceive that you are depressed? HEENT: Have you noticed any neck stiffness? Are there any associated symptoms such as ataxia, nausea, fever, vomiting, altered mental status, binocular vision, dizziness, numbness, weakness, running nose, sore throat, sinus congestion, recent dental work, tooth ache, or double vision? If so, does these symptoms continue between your headaches? Have you noted any sinus pressure, or pain? Have you had any sport related head injuries? Cardio/thoracic: Have you had any issues with your heart? Have you been told that you have a murmur? Have you had any recent blood work, or cardiac studies that came back abnormal? Have you had issues with tachycardia, bradycardia, ectopy, or difficulty catching your breath? Do you suffer from dyspnea, tachypnea, bradypnea, have a cough (productive, or not), asthma, or any pulmonary related conditions/illness that we need to discuss? GI: Has your diet changed? Are you having any abdominal pain, nausea, vomiting, diarrhea, or constipation? GU: Are you having difficulties voiding, straining to void, dysuria, foul odor, not voiding as much, or voiding more than usual? O (Objective) Based on your differential diagnosis list, identify what body systems you will examine along with pertinent positive/negatives in each system and any diagnostic tests you would like to perform. VS: height 5’10” weight 165 pounds BP 96/60, P 78, R 14, T 98.2, BMI 23.7, Z-score is 1.1, 86.2% (Normal stature, overweight)