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NR 603 Week 1 Advanced Clinical Diagnosis and Practice Across the Lifespan

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NR 603 Week 1 Advanced Clinical Diagnosis and Practice Across the Lifespan Week 1 Crystal Quince Chamberlain College of Nursing NR 603: Advanced Clinical Diagnosis and Practice Across the Lifespan October 2017 NR 603 Week 1: PBL Case Discussion: Neurologi...

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  • February 20, 2022
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NR 603 Week 1 Advanced Clinical Diagnosis and
Practice Across the Lifespan




Week 1

Crystal Quince

Chamberlain College of Nursing

NR 603: Advanced Clinical Diagnosis and Practice Across the

Lifespan October 2017

, 2
WEEK 1

NR 603

Week 1: PBL Case Discussion: Neurologic Disorders Part
Two

S (Subjective)

Name: Christopher D. Age: 15 years old Sex: Male Race: White Insurance: NA

CC: Presents with the chief complaint of headache. Christopher D states that headaches occur

one to two times a week and can last one to two days. He puts his hands on his temple and

describes headache as pulsing. He reports pain as 3 out of 5, and was not relieved with 200 mg

of Ibuprofen or Naproxen. No aura. He has been unable to continue whatever task he is working

on (schoolwork, sports etc) when the headaches occur. Sometimes they upset his stomach, but

he has never vomited. Sleep helps sometimes. The only thing that seems to work is distraction,

so he plays Minecraft. The light from the TV hurts his eyes. No trigger identified. He wears

contacts, last visit to eye doctor last month, prescription was updated and he states he sees well.

He can see the board at school without difficulty.

HPI: Christopher D is a 15-year-old boy who presents with his mother. Christopher D is sitting

on the exam table playing on his phone. He does not look up when you enter. His mother

Margaret rises from the chair to greet you. Christopher D looks up and smiles but returns to

looking at the phone until his mother asks him to put the phone away. Christopher D appears his

stated age and is well groomed. You pull up your exam stool in front of Christopher D to ask

him why he is here today. “I get headaches, sometimes they last for days. Mom says all the time

I spend on the computer and looking at my phone is causing them, but I don’t think so.”

Onset: How long have you had these recurrent headaches? Have your headaches been

recurrent? How old were you when this started?

, 3
WEEK 1

Location: Is the pain unilateral, or bilateral? Can you show me what hurts when you

have headaches (frontal, lateral, global)?

Duration: How long does your migraines last? 2 hours? 72 hours?

Characteristics: Does your head aches have a gradual onset, or pulsate? Do you

describe the pain as throbbing, pulsating, squeezing, or some other sensation? Note if he

prefers a dark room.

Aggravating factors: Is there anything in particular that makes your headaches worse? Is

there a pattern? Do your headaches occur when playing the video game?

Relieving factors: Is there anything in particular that helps your headaches, or makes

them go away? Is there anything that you avoid to keep from having a headache?

Treatments/therapies: Do you take anything to make your headaches go away, or do you

have any “rituals” that helps?

Severity: On a scale of 0-10, 10 being “I just want to die it hurts so bad,” what is your

pain level when your headaches are at their worst? Do your headaches interfere with

daily activities? Are your migraines associated with vomiting, photophobia,

phonophobia, or vomiting?

PMHx: Christopher’s mother reports his overall health as good. Have you been diagnosed

with immune deficiency, a malignancy, coagulopathy, or had any head trauma? As far as you

know, have you, or anyone in your immediate family had any cardiac related diseases,

particularly right to left shunt? Do you have a history of hypertension?

Childhood/previous illnesses: None

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