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Assessment of Cognition and the Neurologic System/AN

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Assessment of Cognition and the Neurologic System/AN

Patient Information:

TI, 20, M, Caucasian

S.

CC: Intermittent headache

HPI: The patient is a Caucasian young male adult aged 20 years with complaints about

intermittent headache over the past 3 weeks. He reports that the headache is periodic and when it

occurs the intensity of pain is mostly felt through the nose, around the cheekbones, above the

eyes and on the jaw.

Location: through the nose, around the cheekbones, above the eyes and on the jaw

Onset: sporadic headaches for the past 3 weeks

Character: kicks in with a dull pain that later intensifies to throbbing

Associated signs and symptoms: the patient has been experiencing stress and pressure

resulting from school and work

Timing: the headache recurs at varying times of the day

Exacerbating/ relieving factors: to ease the pain, the patient has been taking coffee,

Ibuprofen and using a cool rag on the forehead.

Severity: pain scale of 8/10

Current Medications: Ibuprofen 400mg PO three times a day.

Allergies: no drug or environmental allergies reported.

PMHX: Immunizations are up to date. Patient denies any surgical and medical history. Flu

Vaccine February 2020. Tetanus vaccine October 2017.

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Social HX: The patient attends college and is undertaking a course in Computer Science. He also

works a part time job in a fast-paced software development company. He currently lives with his

parents. During his free time, the patient reports that he enjoys cycling and listening to rock

music. He often drinks coffer, does not use alcohol but denies ever using any illicit drugs.

Family HX: Both parents are alive. Father is aged 51, very strict and has high blood pressure.

Mother is aged 44 and has no major medical issues. Two younger siblings, twins aged 13 with no

medical issues.

ROS:

GENERAL: patient denies recent illness, major weight loss or gain over the past year, fever or

fatigue.

HEENT: Eyes are sensitive to light during headaches, but denies blurred vision, yellow sclerae

or visual loss. No hearing loss. Inflammation in the nose but denies, nose congestion, running

nose or sneezing. No sore throat.

SKIN: No bruises or rashes.

CARDIOVASCULAR: Denies any chest pain or pressure. No orthopnea or palpations.

RESPIRSTORY: No cough or shortness of breath.

GASTROINTESTINAL: reports anorexia, vomiting and nausea but no abdominal pain.

GENITOURINARY: No issue when urinating.

NEUROLOGICAL: Intermittent headaches. No tingling in extremities, dizziness, paralysis,

syncope or ataxia.

MUSCULOSKELETAL: No back pains, joint pain, stiffness or muscle pain.

HEMATOLOGIC: no bruising or bleeding of gums.

LYMPHATICS: no enlarged nodes.

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PSYCHIATRIC: Denies history of depression.

ENDOCRINOLOGIC: no excessive thirst, hunger or need to urinate.

ALLERGIES: denies history of hives, eczema or asthma.

O:

Physical exam:

General: Patient appears well groomed, and cooperative. Looks nauseated but no signs of

distress.

HEENT: Head- symmetrical, no notable issue. Ears- no bilateral issues. Eyes- clear without

discharge. Nose- clear drainage and no crust observed. Throat: no erythema.

Neck: No neck pain or gross abnormalities.

Cardiovascular: Normal rate and rhythm, no chest pain or peripheral edema. S1 and S2 present.

Respiratory: clear sound in the lungs. No advantageous sounds heard.

Neurological: patient is alert and oriented. Did not experience headache or nausea when being

examined.

Psychiatric: Patient does not exhibit any signs of depression or anxiety.

A.

Differential Diagnoses:

1. Sinusitis: this diagnosis is probable since its symptoms involve inflammation in the nasal

cavity (Dains, Baumann & Scheibel, 2016). Sinusitis also causes facial pain and

headache in all the affected sinuses (Dains et al., 2016). The patient has tender sinuses

and complains of pressure, this fits the diagnosis criteria of sinusitis.

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2. Brain tumor: this diagnosis is possible since consistent headache can indicate elevated

intracranial pressure that occurs when the cerebral spinal fluid flow is obstructed (Wilne

& Walker, 2014).

3. Migraine without aura: this is a very common disorder among adult patients seen by

neurologists (Young, 2018). Patients usually experience unilateral and throbbing

headache and is accompanied by nausea and vomiting, all which the patient has reported

(Young, 2018).

4. Medication rebound headache: A recurring headache associated with the consumption of

caffeine or headache medication (Ball et al., 2015). This headache is associated with

diffuse pain and an individual’s increased caffeine intake and using headache medication

(Ball et al., 2015). The patient reported the use of caffeine and Ibuprofen.

5. Tension-Type Headache: common among adults and starts with mild pain which

gradually escalates to moderate or high pain levels. This type of headache last for a few

hours and is associated with stress (Dains et al., 2016). The patient reported these

symptoms hence the diagnosis.

P:

Not Applicable.
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References

Ball, J. W., Dains, J. E., Benedict, G. W., Vanacore-Chase, D., Flynn, J. A., Solomon, B. S., &

Stewart, R. W. (2015). Student Laboratory Manual for Seidel's Guide to Physical

Examination-Revised Reprint-E-Book. Elsevier Health Sciences.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2015). Advanced Health Assessment & Clinical

Diagnosis in Primary Care-E-Book. Elsevier Health Sciences.

Wilne, S. H., & Walker, D. A. (2014). Could this child have a brain tumour? Signs and

symptoms. British Journal of School Nursing, 9(3), 121-125.

Young, W. B. (2018). Navigating Life with Migraine and Other Headaches. Oxford University

Press.