History of Present Illness (HPI)
Chief 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.
PMH Benning prostatic hyperplasia diagnosed 3 years ago, UTI 6 months ago, Lithotripsy left kidney 10 years ago. No issues after treatment Atrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin Frequent headaches since I was 15, with menses.
Drug Hx Rosuvastatin 20 mg
Olmesartan 20 mg
Losartan 50 mg
Xarelto 15 mg BID
Ibuprofen for Headaches
Subjective
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 episode 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
Objective Data
VS B/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;
General well-developed male, no acute distress well-developed female, no acute distress 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room
HEENT Atraumatic, 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 vision
Lungs CTA AP&L
CTA AP&L
CTA AP&L
Card S1S2 without rub or gallop S4 present Irregular heart beat with normal rate S1S2 without rub or gallop
Abd No tenderness normoactive bowel sounds x 4; No tenderness normoactive bowel sounds x 4;
benign, normoactive bowel sounds x 4;
Rectal exam Warm, swollen and painful prostate gland Non contributory Non contributory
Integument good skin turgor noted, moist mucous membranes intact without lesions masses or rashes. intact without lesions masses or rashes.
Neuro No obvious deformities, CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL
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?
Requirements: 600 WORDS
Answer preview History of Present Illness (HPI)
APA
744 words