XX, 20, Male
CC: “intermittent headaches”
HPI: 20 year old male who complains of experiencing intermittent headaches, which diffuses all over his head. The great intensity and pressure occurs above the eyes and spreads to the nose, cheekbones, and jaw.
Location: Generalized headache
Associated signs and symptoms: Greatest intensity above eyes and spreads to the nose, cheekbone, and jaw
Exacerbating/ relieving factors: Unknown
Current Medications: Unknown
Soc Hx: Unknown
Fam Hx: Unknown
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical
diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Kim, J., Cho, S., Kim, W., Yang, K. I., Yun, C., & Chu, M. K. (2017). Insomnia in tension-type
headache: A population-based study. The Journal Of Headache And Pain, 18(1), 95. doi:
Weaver-Agostoni, J. (2013). Cluster headache. American Family Physician, 88(2), 122-128.
XX, 47, F, Caucasian
CC pain in R) wrist.
HPI: This is 47 year old white female who developed pain in her right wrist 2 weeks ago. The pain causes her to drop her hairstyling tools. She also has numbness and tingling in her right thumb, index and middle fingers.
Onset: two weeks ago
Associated signs and symptoms: numbness and tingling in the thumb and index and middle fingers
Timing: not shared
Exacerbating/ relieving factors: when working the pain in her wrist causes her to drop her hair-styling tools
Severity: not shared
Current Medications: not shared
Allergies: none shared
PMHx: not shared
Soc Hx: occupation of a cosmetologist
Fam Hx: not shared
ROS: Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: No burning on urination. Pregnancy not shared. Last menstrual period not shared
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia. Numbness and tingling in the thumb, index and middle finger on the right extremity. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain or stiffness. Has joint pain in the right wrist.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Physical exam: no information provided.
Diagnostic results: X-ray of wrist – may reveal osteophytes, loss of joint space and fracture (Dains, Baumann & Scheibel, 2016). ESR – indicative of inflammation help in diagnosing arthriris (Dains, Baumann & Scheibel, 2016). Nerve conduction studies confirm carpal tunnel syndrome by detecting median nerve entrapment (Wipperman & Goerl, 2016).
Carpal tunnel syndrome
Carpal tunnel syndrome will have patients presenting with weakness of the hand, dry skin over distribution of the medial nerve; history of repetitive movement, parathesia, weakness and clumsiness of affected hand (Dains, Baumann & Scheibel, 2016). Cardinal symptoms of carpal tunnel will have patient presenting with pain and paresthesia in the distribution of the median nerve, this includes the thumb, index and middle finger; patients will have difficulty holding objects (Wipperman & Goerl, 2016). The patient is presenting with the signs and symptoms that align with the description.
Wrist Fracture will have a patient presenting wit wrist pain that is worse with palpation; patient usually has history of a fall on an outstretched hand and will have pain and swelling of the wrist (Dains, Baumann & Scheibel, 2016). Patients with a wrist fracture will present with pain, radial tenderness, swelling, wrist deformity, hematoma and decreased range of motion (Brants & IJsseldijk, 2015).
Fibromyalgia will have the patient presenting with trigger points on palpation that produce pain, general muscle and joint aches, occurring to those who have a history of depression, sleep disturbance and chronic fatigue (Dains, Baumann & Scheibel, 2016). Patients with fibromyalgia will have tenderness upon palpation of pressure, and chronic pain disorders, widespread pain and no diagnostic tests available to diagnose (Horowitz, 2015).
Osteoarthritis will have patients who present with asymmetrical joint pain and stiffness that improves throughout the day, history of joint trauma and are obese; joints will be enlarged with limited range of motion (Dains, Baumann & Scheibel, 2016). Osteoarthritis has patient’s complaints to be that of joint pain, pain that is disabling to them; this can cause neuropathy to the structure (POLAT, DOGAN, SEZGIN OZCAN, KOSEOGLU & KOCKER AKSLEIM, 2017). Patients at an increased risk will have a history of repetitive weight lifting tasks, some form of joint trauma, are obese or have been diagnosed with diabetes mellitus (Dains, Baumann & Scheibel, 2016).
Tenosynovitis will have patients’ present with pain with movement, swelling over the tendon, crepitus, and history of repetitive trauma of occupational activities, range of motion can be limited (Dains, Baumann & Scheibel, 2016). Tenosynovitis commonly effects the forth extensor compartment and presents as a mass with wrist pain and limited range of motion (Ichihara et al., 2015). Tenosynovitis can present when patients have other chronic medical diagnosis such as gout, rheumatoid arthritis, diabetes mellitus and hyperparathyroidism (Ichihara et al, 2015).
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Brants, A., & IJsseldijk, M. A. (2015). A pilot study to identify clinical predictors for wrist fractures in adult patients with acute wrist injury. International Journal Of Emergency Medicine, 8(1), 1-5. doi:10.1186/s12245-015-0050-y
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Horowitz, S. (2015). Current Understanding of Fibromyalgia: Diagnosis, Treatment, and Theories About Causes. Alternative & Complementary Therapies, 21(1), 25-31. doi:10.1089/act.2015.21101
Ichihara, S., Hidalgo-Diaz, J., Prunières, G., Facca, S., Bodin, F., Boucher, S., & Liverneaux, P. (2015). Hyperparathyroidism-related Extensor tenosynovitis at the Wrist: a general review of the literature. European Journal Of Orthopaedic Surgery & Traumatology, 25(5), 793-797. doi:10.1007/s00590-015-1596-3
POLAT, C. S., DOĞAN, A., SEZGİN ÖZCAN, D., KÖSEOĞLU, B. F., & KOÇER AKSELİM, S. (2017). Is There a Possible Neuropathic Pain Component in Knee Osteoarthritis?. Archives Of Rheumatology, 32(4), 333-338. doi:10.5606/ArchRheumatol.2017.6006
Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management. American Family Physician, 94(12), 993-999.
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