Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
Name
Week 9: Assessment of Cognition and the Neurologic System
Walden University
2022
Case study 1
Patient Information:
Initials: M.O. Male, Age 20, Race; African
Subjective Data:
Chief Complaint: Intermittent headaches
History of Present Illness:
Patient condition history explains a twenty-year-old African male's persistent headaches.
Current Medications:
The patient took Ibuprofen 400 mg PO 6-8hrs for pain relieving.
Allergies:
NKA
Past Medical History (PMHx):
The patient's recorded low blood pressure issue in the last two months has not been confirmed by
a comprehensive medical background. Immunization is up to date
Social History (Soc Hx):
The patient is a college student. No smoking or drinking history.
Family History (Fam Hx):
He has two siblings, younger and stable brothers who don't have a medical problem.
Review of System (ROS):
GENERAL: Neither reported fever nor tiredness.
HEENT: No blurred vision or visual loss
SKIN: No rashes or skin itching.
CARDIOVASCULAR: No chest pain or chest pressure.
RESPIRATORY: No shortness of breath or sinus.
GASTROINTESTINAL: No abdominal pain
GENITOURINARY: No burning when urinating.
NEUROLOGICAL: No numbness or tingling
MUSCULOSKELETAL: No reported stiffness in joints or muscles
HEMATOLOGIC: No bleeding.
LYMPHATICS: no enlarged lymph nodes.
PSYCHIATRIC: No depression
Diagnostic Measures:
Diagnostic measures to be conducted in this case include:
Complete Blood Count (CBC):
The CBC check is based on a variety of anemia, cancer, leukemia, and so forth. The CBC check
helps in this situation to determine if there is any blood disorder in the patient, headache also
being a symptom of anemia (May, 2018).
CT scan:
CT scan can allow a doctor to assess the entire body picture, diagnose and treat some kind of
intra-cranial condition (Donohoe, 2013).
Differential Diagnosis:
Tension-type Headache:
Adult tension headaches can last for days and weeks for various reasons such as job
stress, stress study, etc (Grant, Nazarian & Eshraghi, 2019).
Migraine:
Migraine pain can last for several hours to several days.
Sinusitis: Involves headache, facial pain and fatigue etc (Bugten, Fossum & Nilsen, 2018) are
typical signs of sinusitis.
References:
Bugten, V., Fossum, M., & Nilsen, A. H. (2018). Sinus or nasal surgery alleviates headache
symptoms: A prospective study.
May, A. (2018). Hints on Diagnosing and Treating Headache.BDeutsches Ärzteblatt
International,B115(17), 299.
Grant, J., Nazarian, A., & Eshraghi, Y. (2019). Other Types of Headache. InBPainB(pp. 561-565).
Springer, Cham.
Johnson, K. J., Bauchet, L., Hainfellner, J. A., Kruchko, C., Scheurer, M. E., Wiemels, J., &
Schwartzbaum, J. (2019). Brain tumor disparities: From biology to social determinants-
The 2019 Brain Tumor Epidemiology Consortium meeting report.BClinical
neuropathology.
