A 35-year-old woman presents with recurrent unilateral throb…
Questions
A 35-yeаr-оld wоmаn presents with recurrent unilаteral thrоbbing headaches associated with nausea and photophobia, lasting 6–24 hours. Neurologic exam is normal. What is the most likely diagnosis?
Using the essаy spаce prоvided: Recоrd а cоmplete and thorough physical examination of your patient encounter from Scenario B1, the patient with chest pain. Scenario B1 Reference materials below: Scenario B1 Door Chart Setting Emergency Room Arrived via ambulance Patient Name: Daniel Blank Age: 68 years old Gender: Male Chief Complaint: “I’m having some chest pain and difficulty breathing.” Vital Signs: Temperature: 99.1°F / 36.7°C Heart Rate: 110 beats per minute Blood Pressure: 142/90 mmHg Respiratory Rate: 22 breaths per minute Pulse Oximetry: 93% on RA Weight: 195 lbs / 88 kg Height: 69 inches / 175 cm _____________________________________________________________________________________________ Scenario B1 Case Supplement - Patient History HPI: The pt is a 68 y/o M who presents for the complaint of “I’m having some chest pain and difficulty breathing.” He states that this began late last night without provocation and he has difficulty sleeping as a result. The pain has been stable at 7/10 since onset approximately 6 hours ago. When asked to point to the pain, he reports the pain is located in the right mid chest area and does not radiate. He describes the pain as “sharp”. The chest pain is worse with taking a deep breath, without other known exacerbating factors. No known alleviating factors. No history of similar issues in the past. Pt adds that he had surgery 4 days ago, reporting that he had a right-sided total knee replacement due to arthritis problems that he suffered from for years. He reports he has been closely following his post-operative physical therapy plan and wearing his soft brace as directed. Associated symptoms include some mild to moderate dyspnea with exertion since the surgery and right knee area pain and swelling since the surgery (pt is currently in a soft immobilizer brace) which has not changed. There is, however, new left lower extremity pain and swelling as of 2 days ago located in the lower leg area beyond the knee. That is worse with ambulation / weight bearing on the left side. Pt denies fever/chills, cough, runny nose, recent URI symptoms otherwise. He denies arm pain, neck pain, or headache. No new numbness or weakness anywhere. No syncope, dizziness, or light-headedness. Past Medical History (PMHx): Illnesses/Injuries: Hypertension, Osteoarthritis, Hyperlipidemia, Overweight Hospitalizations: Recent hospitalization for R Total Knee Arthroplasty (TKA), released 3 days ago; One prior hospitalization for injuries sustained after a fall from a ladder 25 years ago. Surgical History: R Total Knee Arthroplasty (TKA) - 4 days ago; No other major surgeries reported Screening/Preventive History: Up-to-date on adult vaccines with exception of COVID and influenza vaccines, which pt has declined yearly for the last 4 years. Medications (Prescription, Over the Counter, Supplements): Lisinopril 10mg PO daily, Tylenol 1000mg PO BID PRN pain, Atorvastatin 20mg PO QHS Allergies (e.g. environmental, food, medication and reaction): -No known drug allergies Family Medical History: Mother (deceased, age 70) had history of asthma, osteoporosis, DM 2Father (deceased, age 88) had history of dementia, hyperlipidemia Sister (alive, 65) has history of depression, hypertension Daughter (alive, 40) healthy Son (alive, 39) healthy No genetic disorders in family Social History: Substance Use / Alcohol Use: None Tobacco Use: None Diet: Low sodium diet followed per patient due to history of high blood pressure Home Environment: Lives with wife in a single-story home, feels safe at home Occupation: Retired optician Leisure Activities: Book club, beach-combing, puzzles, church Exercise: Walking along the beach, played tennis until about 2-3 years ago Sleep: 6-7 hours per night normally Religion: Christian Sexual: Sexually active with wife only ROS (Review of Systems): General: Feels fatigued since the surgery, otherwise no weight loss or gain recently. No disorientation. Skin: Surgical wound overlying right knee reported to have some mild bruising, but no reported discharge, erythema or bleeding. The left calf area is reported to have some redness and warmth to the touch. No lesions, lacerations, wounds, or eczema otherwise. HEENT: No headache, neck pain/stiffness, no sore throat. No vision changes or congestion/runny nose. Respiratory: See HPI. No cough, wheezing, hemoptysis. Cardiovascular: See HPI. No palpitations, syncope, diaphoresis. Gastrointestinal: +Nausea without vomiting and mild constipation since surgery. No change in appetite. No reported abdominal pain, blood in stool, or diarrhea. Genitourinary: No urinary frequency, dysuria, hesitancy, urgency, or foul-smelling urine. Musculoskeletal: See HPI. No other new joint swelling or pain. No back pain, neck stiffness, or crepitus. Psychiatric: No depression, anxiety, insomnia or SI/HI. Hematologic: No easy bruising or bleeding. No known blood clot(s) in the past. No history of blood clotting disorder. Endocrine: No hot/cold tolerance, hair loss, or nail changes Neurologic: No dizziness, confusion, memory loss, numbness or tingling.
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