Some of the subjective data that I would obtain from the patient include the patient demographics
Case Study 3
Subjective Data to Obtain
Some of the subjective data that I would obtain from the patient include the patient demographics such as age, race, gender, and what they do for a living. I would also enquire about the patient’s information, such as when the headache began, the exact location, and how the headache causes pain and discomfort to the patient. I will also ask the patient how the pain has changed since the onset, the frequency, and the nature of the discomfort. I will enquire if there is anybody close to the patient who has the same symptoms, if they have any agitating and alleviating factors, any drugs used, and travel history. I will also review other systems to come up with subjective data.
Objective Findings to Look For
I would conduct a series of objective findings to determine the source of the headaches. I will do this by observing the signs and symptoms the patient is having, for example:
- Lack of balance,
- Inappropriate behavior
- Dizziness
- Excessive fatigue
- High blood pressure
- Infection
- Loss of consciousness
- Mental confusion
- Muscle weakness, numbness, or tingling
- Nausea, vomiting
- Seizures
- Speech difficulties
- Vision changes
Diagnostic Exams to Order
To arrive at a definitive conclusion, further tests must be conducted to rule out other medical conditions that could also be causing headaches. Some of the tests that need to be conducted include;
- Urinalysis and blood chemistry tests. A urinalysis is an examination of the urine. In general, urine is collected in a sterile container and then analyzed for one or more of the following: the presence of glucose, ketones, blood, pH, protein, nitrite, bilirubin, urobilinogen, specific gravity, and creatinine (Zhang et al., 2022). A blood chemistry test or blood work is a laboratory analysis of substances in the blood. Often blood chemistry tests are used to assess organ function and detect disease.
- CT scan and MRI: CT and MRI are both medical tests used to examine the human body. The main difference between these two is that CT scans use a series of X-rays to take a long look at the different layers of the body, whereas MRIs use magnetic and radio waves. MRIs are better for studying the brain and spine, whereas CT scans are better for studying bones.
- Eye exam; Examining the eye is one of the most important and often overlooked aspects of a physical examination. The eye is composed of the soft, jelly-like tissue called the vitreous behind the lens and surrounded by the retina. Because they are not protected by bone, the vitreous and retina are easily injured. The retina comprises cells that respond to light and send images to the brain. The macula, a small area in the retina, s responsible for recognizing fine detail. The macula has a layer of cells sensitive to light called photoreceptors, which convert light into electrical signals. The brain interprets these signals to create the image seen in the eye.
Differential Diagnoses
- Cerebral aneurysm
- Cluster headache
- Tension-type headache
Rationale For Each
A cerebral aneurysm can be a life-threatening condition in which a blood vessel in the brain bursts (Sheikh et al., 2020). The aneurysm usually has a thin, dented wall that bulges outward and may leak blood, leading to a hemorrhagic stroke or bleeding into the brain tissue, which can lead to an ischemic stroke. A cerebral aneurysm is most commonly the result of old age, high blood pressure, and smoking.
Cluster headache; It is often called the “suicide headache” because of the pain it can cause. It is a type of trigeminal autonomic cephalalgias (TAC), a neurological disorder characterized by brief recurring attacks of intense pain in one area of the head and symptoms that are not caused by structural problems or illness.
Tension-type headache is a common type of headache. It is not life-threatening and does not cause bleeding or brain damage. Tension-type headaches are the most common type of headache resulting from muscle contractions in the neck and face. People usually experience dull, aching pain on both sides of the head. The pain can be made worse by any activity involving straining muscles, such as holding their head or turning it.
Teachings to provide
- Behavior modification
- Proper dietary practices
- Regular exercise
- Meditation exercise.
References
Sheikh, M. A. A., Shuib, A. S., & Mohyi, M. H. H. (2020). A review of hemodynamic parameters in cerebral aneurysm. Interdisciplinary Neurosurgery, 22, 100716. https://doi.org/10.1016/j.inat.2020.100716 (Links to an external site.)
Zhang, Z., Liu, J., Cheng, Y., Chen, J., Zhao, H., & Ren, X. (2022). Urine Analysis has a Very Broad Prospect in the Future. Frontiers in Analytical Science, 13. https://doi.org/10.3389/frans.2021.812301 (Links to an external site.)
Edited by Torres, Yumays on Jul 26 at 3:19pm
6 mins ago
there’s no post yet for case 1, if you want just send any commend regarding urinary retention, Benning prostatic hyperplasia
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