iHuman Case Study and H&P Assignment

ByDaniel Rossi Updated on

iHuman Case Study and H&P Assignment

iHuman Case Study and H&P Assignment

iHuman interaction needs to be completed and the H&P which a template is attached. I will provide login info when needed for iHuman. Instructions below…

The next case is Jacqueline Russell. This is a learning mode case (0% or 100%) and is graded and required. I will move the due date for this case to 9/16/2020.

We will adjust the date on the next case next week as needed.

Here are the important things with iHuman:

  • You MUST use the Template (attached) for the Plan. Either admission or outpatient!
  • No HPI, CC, or other commentary goes in the order set. Points are deducted for this unnecessary information on graded cases and you will get no credit on the learning mode cases. This is an order set, thus no additional information is appropriate here.
  • The HPI goes in the HPI section. See the resources in Doc Sharing. Failure to have a billable (as in good quality) HPI or if the HPI is missing results in ZERO points on the iHuman.

ORDER COMPREHENSIVE SOLUTION PAPERS

To prepare:

  • Review the Learning Resources for this week in preparation to complete this week’s i-Human case study. Based on the provided patient information, think about the health history you would need to collect from the patient
  • iHuman case study and H&P Assignment
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition. Reflect on how the results would be used to make a diagnosis.
  • Identify three to five possible conditions to consider in a differential diagnosis for the patient.
    Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
    Reflect on a treatment plan for the patient that includes health promotion and patient education strategies.
  • Consider the potential impact a patient’s psychosocial health may have on treatment plans, including health promotion and patient education strategies.

iHuman Case Study: Differential Diagnoses to a Client with Headache

Tension-type headache (TTH): Tension-type headache is identified by a consistent sensation of pressure that usually starts at the forehead, temples, or the base of the neck, according to Smeltzer et al. (2019). This type of headache is often described as a tight band or a heavy weight pressing on top of the head. TTH is the most common type of headache, often usually bilateral and non-radiating, and can be triggered by stress and anxiety. TTH can be chronic, and its intensity can gradually increase throughout the day. The patient’s stress level and recent traumatic experience with her boyfriend are potential risk factors for TTH.

Migraine without aura: Migraine headaches are characterized by throbbing pain, usually on one side of the head, nausea, and light sensitivity. However, some people experience migraines without aura, which can present with symptoms similar to tension-type headaches, such as the patient’s symptoms of a dull, pressure-tight cap around the head (Smeltzer et al., 2019). Additionally, post-traumatic headache can also be a differential diagnosis. The patient’s recent history of wrist trauma after being pushed by her boyfriend, coupled with bruises on her left arm and breast, could suggest a possibility of post-traumatic headache. This type of headache can occur after a head injury or trauma and may not present immediately after the incident. In this case, the headache may have started after the wrist injury and gradually worsened.

Depression: The patient’s current social situation, with an abusive boyfriend and being disowned by her mother, can indicate a possibility of an underlying depressive disorder. Chronic stress and anxiety, which are often associated with depression, can also trigger headaches (Fava, 2021). Depression can present with physical symptoms, including headaches, fatigue, and body aches (Varcarolis & Dixon, 2020). The patient’s withdrawal and edgy behavior could be related to depression. It’s important to note that these are just potential differential diagnoses and a thorough medical evaluation by a psychiatric mental health nurse is needed to confirm a diagnosis and develop an appropriate treatment plan. Additionally, it is important to address the patient’s safety concerns and potential abuse by her boyfriend.

References

Cosci F., & Fava, G. A. (2021). When anxiety and depression coexist: the role of differential diagnosis using clinimetric criteria. Psychotherapy and Psychosomatics, 90(5), 308-317.

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2019). Brunner and Suddarth’s textbook of medical surgical nursing: In one volume (12th ed.). Lippincott Williams and Wilkins.

Varcarolis, & Dixon. (2020). Essentials of psychiatric mental health nursing – Elsevier eBook on vitalsource (retail access card): A communication AP (4th ed.). Elsevier Science Publishing. https://cir.nii.ac.jp/crid/1131694358645353473