Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
Mention the health promotion intervention for this patient.
What did you learn from this week's clinical experience that can beneficial for you as an advanced practice nurse?
Sample Solution
Patient: A 34-year-old female presenting with recurrent headaches
Signs and Symptoms (S&S): Patient reports experiencing 8/10 intensity, bilateral frontal headaches that develop over the course of 20 minutes and last for 3 to 4 hours. She also experiences nausea, photophobia, and phonophobia. No focal neurological deficits are noted on exam.
Assessment: Headache is a commonly reported symptom often seen in primary care settings; however, it can be caused by an underlying pathology or medical condition such as migraines or intracranial lesions. Given the patient’s presentation with frequent recurrence of severe headache along with associated symptoms of nausea, photophobia, and phonophobia this could suggest a diagnosis of migraine headaches secondary to cranial vascular dysfunction. The differential diagnoses should include meningitis/encephalitis due to headache being one of the common constitutional symptoms; hypothyroidism due to thyroid abnormalities potentially causing bouts of headache; temporal arteritis due to its association with recurrent unilateral jaw claudication and headache; as well as subarachnoid hemorrhage due to severe “worst ever” type headaches that can have abrupt onset followed by decreased level consciousness.