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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.

MINE IS CASE #3

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.

PMH

Benning 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 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 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

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 distresswell-developed female, no acute distress25-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 presentIrregular heart beat with normal rateS1S2 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 glandNon contributoryNon contributory

Integument

good skin turgor noted, moist mucous membranesintact without lesions masses or rashes.intact without lesions masses or rashes.

Neuro

No 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?

  
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