Do you need this or any other assignment done for you from scratch?
We have qualified writers to help you.
We assure you a quality paper that is 100% free from plagiarism and AI.
You can choose either format of your choice ( Apa, Mla, Havard, Chicago, or any other)
NB: We do not resell your papers. Upon ordering, we do an original paper exclusively for you.
NB: All your data is kept safe from the public.
Patient information
Patient: N. A.
Sex: Male
Age: 20
Race: American
CC: Intermittent headaches.
HPI: the patient complains of headaches that occur with a particular frequency and focus. The most intense pain concentrates above the eyes and then spreads to the nose, cheekbones, and jaw.
Location: head, above eyes, through nose, cheekbones, and jaw.
Onset: intermittent headaches over the last month.
Character: aching pain in the whole head and painful, severe throbbing in the region of the nose and temples.
Associated signs and symptoms: an increased level of workload and tension because of the approaching deadline for the project at work. Based on the above, the patient disrupts the regular work and rest schedule and is under stress.
Timing: headaches occur mostly in the evening.
Exacerbating/ relieving factors: patient reports taking Ibuprofen to help with the pain.
Severity: 7/10 pain scale at its greatest intensity.
Current Medications: The man tries to resort to pills only with severe pain, drinks 1 Aspirin tablet every two days for two weeks.
Allergies: The patient reports that he does not have any allergies.
PMHx: At the age of seven, his arm was broken without complications. In recent years he has not had anything more severe than a seasonal cold. Tetanus vaccination was given on 08.2018, and there were no operations.
Soc Hx: The young man has already graduated from college with a degree in management and administration. He works in his first office job as a Client Relationship Manager and gets there by car. It is essential for him to do the tasks quickly and competently; therefore, he tries very hard. As a hobby, he is engaged in fishing, reading books, and playing computer games. He has a girlfriend with whom they do not live together yet. The man lives alone in a small flat, does not smoke or drink alcohol, only on holidays in small quantities.
Fam HX: The patient’s mother suffers from severe migraines, and this may be a genetic predisposition. However, in this case, usually only half of the head hurts, and not the whole. The father has diabetes mellitus among chronic diseases. Grandparents are alive, both suffering from bone pain and memory loss. Great-grandmother and great-grandfather died of old age at the age of 80-85.
Ros
GENERAL: The patient says the condition is generally stable; there is no nausea, fever, body pain. There is a headache, lethargy, rapid fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, nose, throat: Denies pain symptoms, hears well, the throat does not hurt, there is no runny nose or congestion.
SKIN: The patient says no skin lesions, no visible signs of disease or rash.
CARDIOVASCULAR: The man notes no discomfort and pain in the chest.
RESPIRATORY: The patient says breathing is not difficult, there is no cough.
GASTROINTESTINAL: He denies nausea, vomiting, and rapid weight change.
GENITOURINARY: The patient says no burning on urination.
NEUROLOGICAL: The man denies limb numbness, neck pain, speech impairments, and seizures.
MUSCULOSKELETAL: The patient denies muscle pain throughout the body.
HEMATOLOGIC: The man rejects anemia and bleeding.
LYMPHATICS: The patient denies enlarged notes.
PSYCHIATRIC: He suffers from depression about three years ago due to difficulties in college, prone to anxiety.
ENDOCRINOLOGIC: The man denies sweating, cold, or heat intolerance.
ALLERGIES: The patient rejects any allergies.
Physical exam
GENERAL: Visible signs of the disease are found only on the face. They appear as bruises under the eyes and pallor of the skin.
HEENT: Eyes: Eyesight examination showed no abnormalities The pupil is normal, the sclera is slightly reddened. Ears, nose, throat: The sinuses are slightly blocked, the ears are normal, the throat is not irritated.
CHEST: Breathing is not difficult; heart rate is stable.
BELLY: Abdominal cavity in the normal state is not inflated.
SKIN: On the skin, there are no sores or spots.
Diagnostic results: The problem of headache is most often related to neurology. Doctors order several tests such as MRI, computed tomography, electroencephalogram, eye nasal examinations, blood and urine tests (Benisek, 2020). Considering the information obtained during the examination and filling out the patient’s questionnaire, it is worth starting with an assessment of the sinuses and eyes. X-rays of the sinuses should be done to determine if the nasal congestion is present, as this can be difficult to visualize visually (Hain, 2021). Then it is worth paying attention to the eyes, and it is this place that speaks in the likelihood of many diseases. After that, the doctor must do an MRI and check the overall brain function.
Differential diagnosis: The first likely diagnosis is the tension headache. It is consistent in symptoms such as dull pain throughout the head, pressure on the forehead and temples. It is often a symptom of another disease, and the most common provocateur of this pain is stress. Additionally, it is typical for people with psychiatric symptoms, and the patient was depressed (Sınal & Akalın, 2020). The second possible diagnosis is migraine. According to Charles (2018), it is a complex variable dysfunction of the nervous system and not just a vascular headache. Sinusitis can be considered a third option since the problem of complications of nasal congestion is not always obvious. It fits the criteria for a dull headache in the face area. It happens because of the activation of the ternary nerve, which is located near the sinuses (Rodriguez et al., 2018). An accurate diagnosis requires an examination by a neurologist and basic tests.
References
Benisek, A. (2020). Your first neurology appointment for migraines. WebMD.
Charles, A. (2018). The pathophysiology of migraine: implications for clinical management. The Lancet Neurology, 17(2), 174–182.
Hain, T. C. (2021). Sinus headache. Dizziness-and-Balance. Web.
Rodriguez, L. M., Alvarez, A. I. P., & Alvarez, J. M. S. (2018). Cluster-like headache secondary to maxillary sinusitis by aspergillus. Cephalalgia Reports, 1. Web.
Sınal, A., & Akalın, T. (2020). Psychological symptoms in young adults with tension type headaches. American International Journal of Social Science, 9(1). Web.
Do you need this or any other assignment done for you from scratch?
We have qualified writers to help you.
We assure you a quality paper that is 100% free from plagiarism and AI.
You can choose either format of your choice ( Apa, Mla, Havard, Chicago, or any other)
NB: We do not resell your papers. Upon ordering, we do an original paper exclusively for you.
NB: All your data is kept safe from the public.