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. CASE #2
Case 1Case 2Case 3Chief Complaint
(CC) “It burns when I urinate”“I had a severe headache yesterday with difficulty to speak” “I have been having frequents headaches lately”History of Present Illness (HPI)A 68-year-old Caucasian male who reports to have increase on the frequency of urination with urgency for the last 5 days. He also present dysuria and nocturia.A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk with last for about two hours. She did not seek medical attention. This morning she woke up with no problems but is here today due her husband advise. A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile.PMHBenning prostatic hyperplasia diagnosed 3 years ago, UTI 6 months ago, Lithotripsy left kidney 10 years ago. No issues after treatmentAtrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin Frequent headaches since I was 15, with menses. Drug HxRosuvastatin 20 mg
Olmesartan 20 mg
Losartan 50 mg
Xarelto 15 mg BID
Ibuprofen for HeadachesSubjective
Fever and chills, no changes in vision or hearing, no difficulty chewing or swallowing. No sexually active, nocturia, dysuria.
Yellowish urethral secretion. Feels Palpitations, joint pain with yesterday’s episodeLight 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-dayObjective Data VSB/P 150/96; Pulse 89; RR 16; Temp 99.4; Ht 6,1; wt 180; B/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%; B/P 108/64; Pulse 86; RR 16; Temp 98.6;
Generalwell-developed male, no acute distresswell-developed female, no acute distress25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition.
no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal visionLungsCTA AP&L
CTA AP&L
CTA AP&LCardS1S2 without rub or gallop S4 presentIrregular heart beat with normal rateS1S2 without rub or gallopAbdNo tenderness normoactive bowel sounds x 4; No tenderness normoactive bowel sounds x 4;
benign, normoactive bowel sounds x 4;
Rectal examWarm, swollen and painful prostate glandNon contributoryNon contributoryIntegumentgood skin turgor noted, moist mucous membranesintact without lesions masses or rashes.intact without lesions masses or rashes.NeuroNo obvious deformities, CN grossly intact II-XIINo obvious deficits and CN grossly intact II-XIICranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL
Once you received your case number, answer the following questions:
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient presenting symptoms?
Give rationales for your each differential diagnosis.
What teachings will you provide?
Expert Solution Preview
Introduction:
As a clinician, I would like to gather additional subjective data, look for objective findings, order diagnostic exams, propose possible differential diagnoses for the patient’s symptoms, and provide relevant teachings.
1. What other subjective data would you obtain?
I would obtain information about the patient’s past medical history, specifically focusing on any previous urinary tract infections, urological procedures, or other significant urologic conditions. Additionally, I would inquire about the presence of any systemic symptoms such as fever or chills, changes in vision or hearing, difficulty chewing or swallowing, and any recent sexual activity.
2. What other objective findings would you look for?
Apart from the provided objective data, I would examine the patient’s abdomen for any tenderness or organomegaly. It would also be pertinent to perform a thorough neurological examination to assess for any deficits that could be contributing to the patient’s symptoms. Furthermore, a detailed examination of the eyes, including fundoscopy, should be conducted to evaluate for any signs of increased intracranial pressure.
3. What diagnostic exams do you want to order?
Based on the patient’s symptoms and clinical findings, several diagnostic exams could be considered. These may include a urinalysis with microscopy to assess for urinary tract infections or abnormalities, a prostate-specific antigen (PSA) test to evaluate prostate health, and a complete blood count (CBC) to check for any signs of infection or inflammation. Additionally, neuroimaging studies such as a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the head may be necessary to identify any structural abnormalities.
4. Name three differential diagnoses based on this patient’s presenting symptoms?
a) Urinary tract infection: Given the patient’s dysuria, nocturia, increased frequency of urination, and yellowish urethral secretion, a urinary tract infection is a possible differential diagnosis.
b) Migraine headache: The patient’s severe pulsatile headache with photophobia, nausea, and associated relief with rest and sleep suggests a possible migraine headache.
c) Temporal arteritis: With the patient’s headache localized to the right temporal area, associated visual symptoms, and the fact that light worsens the headache, temporal arteritis should be considered.
5. Give rationales for each differential diagnosis.
a) Urinary tract infection: The patient’s symptoms of dysuria, nocturia, and yellowish urethral secretion are indicative of a urinary tract infection. A urinalysis can provide insights into the presence of white blood cells and bacteria, further supporting this diagnosis.
b) Migraine headache: The patient’s symptoms of severe pulsatile headache, associated photophobia and nausea, as well as relief with rest and sleep, are consistent with migraine headaches. A thorough history focusing on the characteristics and triggers of the headaches would provide additional support for this diagnosis.
c) Temporal arteritis: This differential is considered due to the patient’s complaint of a headache localized to the right temporal area and the aggravation by light. Further questioning about any systemic symptoms, such as weight loss, jaw claudication, or vision changes, would be vital to support this diagnosis.
6. What teachings will you provide?
I would educate the patient about the importance of maintaining good urologic health, including methods to prevent urinary tract infections. This could involve proper hygiene practices, avoidance of irritants, and techniques to ensure complete bladder emptying. Additionally, I would provide information on recognizing and managing migraines, including lifestyle modifications, stress reduction techniques, and appropriate use of abortive or preventive medications. For temporal arteritis, I would emphasize the need for prompt medical attention to prevent potential complications, such as vision loss, and discuss the role of corticosteroids in its management.
By addressing these discussion points, the clinician can effectively assess the patient’s symptoms, consider potential diagnoses, and provide appropriate teaching and care.
