case study

Martha Hernandez

22 years old female, 5 7 tall, 118lb 53.6kg

Chief complaint: bad throbbing deep headache since yesterday and hasn’t gotten any better and also feel a bit nauseated, she unable to do anything. Rating 8/10, start when she was working on term paper

What she thinks might be cause headache: I’ve been pretty stressed out lately

Pt has history of headache for long at interval of 4 to 6 week they are getting more worst and painful headache start from temple and radiate to the whole head

Headache: one that is relieve with Tylenol and other that is relieve with lying down in bed in the Dark

Headache: she tried coffee but it makes it worst, her headache can induce by red wine

She feels nauseous at the same time and loud noise bother her

Start when am awake and never keep me from sleeping

How long it last: it happens more often

No patterns to the headache, start gradually and get progressively worst

Sister has frequent headache and mother sometimes want to lie down alone in the dark

2 Tylenol tablets every 4 hours since the headache start

It doesn’t come and go once it started it last usually last more than a day.

Nausea: stomach unsettled and doesn’t feel like eating or drinking

PLEASE CONSIDER EVERTHING UNDER DIAGONOSIS FOR HEADACHE AND NAUSEOUS

I. Management Plan: Use the expert diagnosis provided to create a pertinent comprehensive evidence-based management plan. If a specific component of the management plan is not warranted (i.e., no referrals are appropriate for the virtual patient) document that no intervention is warranted. Include the following components:

i. diagnostic tests

ii. medications: write a specific prescription for each medication, including over-the-counter medications

iii. suggested consults/referrals

iv. client education

v. follow-up, including time interval and specific symptomatology to prompt a sooner return

vi. cite at least one relevant scholarly source as defined by  program expectationsLinks to an external site.

vii. Click "Submit" once the case is complete. Use this guide to  download the Performance Overview Report Links to an external site. .

II. Reflection: One rule is to always include “the worst-case scenario” in your differential diagnosis and make sure you have ruled out this possibility based on your findings and patient assessment. Your goal is to minimize the risk of missing unusual or infrequent conditions such as meningococcal meningitis, bacterial endocarditis, pulmonary embolus, or subdural hematoma that are particularly ominous. 

Address the following question:  What are the "red flags" in this case? Based on your pertinent key findings, what is "the worst-case scenario"? What lessons did you learn from this case that you can apply to your future professional practice? Include the following components:

i. write 150-300 words in a Microsoft Word document

ii. demonstrate clinical judgment appropriate to the virtual patient scenario

iii. cite at least one relevant scholarly source as defined by program expectations

iv. communicate with minimal errors in English grammar, spelling, syntax, and punctuation