Double Health History

The physical Assessment Findings: The patient’s head, eyes, ears and nose are normal, however there is white patches on the buccal mucosa. The lymph nodes and carotid bruits are absent. Her heart beat at a regular rate and rhythm without murmur. Her lungs sound is diminished to auscultation with end expiratory wheezes, and dull percussion to the right lower lobe. Her anterior-posterior diameter of the chest wall is also increased. Her abdomen is benign. She has strong pedal pulses to all extremities without edema.

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

He also had right more than left mastoid opacifications and states that he was recently treated for otitis media. He has hypertension, hyperlipidemia, coronary disease and had been noncompliant with his medications in the past. His exam was essentially normal except for the subjective vertigo. There was no nystagmus and no diplopia on the initial exam. On 06/19/2015, he gave a different history. He states that he had a strike to the left temporal on Tuesday 06/16/2015. This did not result in any vertigo or any other neurological symptoms at that time. It was two days later that he had the vertigo at work. The patient also claimed that he had been seeing double since the previous night and the morning of the 19th. However, his neurological exam at that time, failed to reveal any actual disconjugate gaze. The patient had an MRI MRA, which revealed old white matter ischemic disease and mild intracranial atherosclerosis, but no evidence for acute stroke or posterior circulation significant stenosis. His diagnosis was labyrinthitis, possibly due to his bilateral mastoiditis. He was treated with Augmentin for 10 days. His symptoms resolved prior to discharge on meclizine. On physical therapy on discharge, he had no

In the past, they have been on the average of one everyone and half weeks. They start at the vertex and radiate to the nuchal area and retrobulbar area. They are throbbing, worsen with exertion. She has nausea, photophobia, and phonophobia with these. Precipitants include stress. She has never been on any prophylactic medications or triptans. She had a severe migraine a few months ago, resulting in a dull, daily headache for one month. She had another severe migraine two weeks ago, which was present for a whole week. She had a spinal tap done. She previously had negative serum Lyme titers. The CSF Lyme Western blot was positive for four bands. Her primary care physician did give her a course of doxycycline. The emergency room gave her Tramadol, which does not work. She has been using Tylenol with Motrin two to three days out of the week. Family history includes a sister and

The patient was seen on June 1, 2015 secondary to vertigo. These symptoms did resolve completely.

Patient is a 34-year-old left-handed white male who states that in January he was in a parking lot and was hit by a plow truck that was backing up. His back was turned and he did not know what was happening. He fell on his back and hit the back of his head on the tailgate. He denied any loss of consciousness. He did have a significant headache and neck pain, but no neurological symptoms. He did have some pain in his right hand and right ankle after this. He did present to the emergency room, where an unenhanced CAT scan was negative. Since then however, he has been having daily headaches. He has an almost constant, dull, mild bitemporal pressure sensation, but he also has significant

Patient denies any signs or symptoms of GI bleeding, N/V/D, bloody stool, chest pain, SOB, or blurred vision. Patient was in a fight over 20 years ago and has facial bone damage, now that is affecting his vision. Requesting community resources Patient was seen at Calhoun Eye Center several years ago.

The 32 year old patient is presenting with chronic headaches. Subjective data indicates over the eye throbbing or pressure that spreads to the ipsilateral temple which typically occurs on the left side. This headaches occur with extremely light and sounds which become aggravated with movement. Given this information, it is necessary to explore additional questions. According to Guilbea and Lenahan (2015) the health history questions are key to making a diagnosis as it will help to rule out another diagnoses. They questioned presented to the patient are listed below. Question one will identify whether the headache is primary or secondary. Using the well-established PQRST pain method, the questions are designed based on this method. For question two the P aspects of pain which stands for provocating and precipitating factors. In question three, the Q stands for quality of pain. Question four addresses the R which stands for radiation. The patient did report it moves which is an area that requires further

B.R. is a 10-year-old previously healthy female that presented with persistent cough after a failed outpatient therapy for pneumonia. Two weeks ago she developed a sore throat and intermittent fever. She was seen by her PCP, where her strep test tested negative; therefore, she was diagnosed with a viral upper respiratory infection. She later developed significant left upper quadrant abdominal pain and was in bed for two days. She was seen again by her PCP, where she was diagnosed with constipation. She continued to have pain and fever; therefore, her parents took her to Kaweah Delta Hospital where and ultrasound was done. The ultrasound, monospot test, and strep test performed at Kaweah Delta were all negative. They then performed a CT and

Mr. S, a 69-year-old patient was admitted into the hospital, after he presented at home a sudden severe headache, vomits and neck stiffness. In A/E this patient presented a Glasgow Coma Scale (GCS) of 15/15 (E-4, V-5, M-6), both pupils, equal and reactive to light (3mm) and normal motor power. Also he complained about severe pain in his head, which was measured at 7/10, using the numeric pain scale (which 0 means “no pain” and 10 means “extreme pain”) (British Pain Society, 2006).

Patient is a 26-year-old right-handed white female who presents with her husband for followup after a vertebral dissection and stroke. This is an individual who has a long history of migraines. They went away during her pregnancy. Her child is six months old. After pregnancy, they started to recur again. She had a migraine on August 1, 2015 that was very severe and included intractable nausea and vomiting. For this she went to Wentworth Douglass Hospital Express care, where she was treated with medication for the symptoms. She went home, but later that night noted that the symptoms worsened, and she started having some visual field problem. At the time, she was lying on the sofa

The patient had not been eating and was complaining of pain in her mouth. The patient’s chest view showed central line in place, mild basilar atelectasis with no focal lung consolidation. The patient has fever but is not neutropenic, and the patient’s HSV testing was negative for Herpes Simplex Virus I & II. In addition, the patient’s urine Culture is < 10,000 CFU/ML non-lactose fermenter, oxidase (-) and the patient’s blood culture has been negative in the last 48

patient was not having any pain or significant discomfort in the area. The throat was

Head: skull symmetrical w/ normal contour, no bumps, swelling or tenderness; TMJ normal ROM, no pain or clicking; temporal arteries

Nose: Nares patent without any obstruction. No frontal or maxillary tenderness during palpation of the sinus cavities.