For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Once you received your case number, answer the following questions:
Chief Complaint
(CC)
History of Present Illness (HPI)
PMH
Drug Hx
Subjective
Objective Data
VS
General
HEENT
Lungs
Card
Abd
Rectal exam
Integument
Neuro
“I have been having frequents headaches lately”
“I have been having frequents headaches
lately
A 25-year-old Hispanic female presents to
your clinic with a headache located on right
temporal area, pulsatile.
Frequent headaches since I was 15, with
menses.
Ibuprofen for Headaches
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
B/P 108/64; Pulse 86; RR 16; Temp 98.6;
25-year-old female appears well developed
and well-nourished, healthy appearing,
wearing dark glasses in a dim room
no injection, anicteric, PERRLA, EOMs intact,
without pain to movement; normal vision
CTA AP&L
S1S2 without rub or gallop
benign, normoactive bowel sounds x 4;
Noncontributory
intact without lesions masses or rashes.
Cranial nerves II to XII intact; sensation intact,
DTRs 2+ throughout.
Functional neurological exam is WNL
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