Neurological and Male Genitourinary Disorders Case Study (Case Study Sample)
(CC) “I have been having frequents headaches lately”
History of Present Illness (HPI) A 25-year-old Hispanic female presents to your clinic with a headache located on right temporal area, pulsatile.
PMH Frequent headaches since I was 15, with menses.
Drug Hx Ibuprofen for Headaches
Subjective Light makes headache worst Nausea associated with headaches. No vomiting, Headaches improve usually with rest, ibuprofen, and sleep, but it is annoying to have to sleep all-day
VS B/P 108/64; Pulse 86; RR 16; Temp 98.6;
General 25-year-old female appears well developed and well-nourished, healthy appearing, wearing dark glasses in a dim room
HEENT no injection, anicteric, PERRLA, EOMs intact, without pain to movement; normal vision
Lungs CTA AP&L
Card S1S2 without rub or gallop
Abd benign, normoactive bowel sounds x 4;
Rectal exam Non contributory
Integument intact without lesions masses or rashes.
Neuro Cranial nerves II to XII intact; sensation intact, DTRs 2+ throughout.
Functional neurological exam is WNL
Once you received your case number, answer the following questions:
1. What other subjective data would you obtain?
2. What other objective findings would you look for?
3. What diagnostic exams do you want to order?
4. Name 3 differential diagnoses based on this patient presenting symptoms?
5. Give rationales for your each differential diagnosis.
6. What teachings will you provide?
Neurological and Male Genitourinary Disorders Case Study
Neurological and Male Genitourinary Disorders Case Study
Other Subjective Data I Would Obtain
The other subjective data that I would obtain from the patient is Urinary incontinence frequency. It is quite important to consider their inability to control one's bladder. It would be a frequent and uncomfortable condition for the patient. The intensity might range from sometimes spilling urine when people are sneezing or coughing to having a sudden and intense desire to urinate that prevents them from reaching the toilet in time (Espay, Aybek, Carson, A., Edwards, Goldstein, Hallett, & Morgante, 2018). Urinary incontinence is not a natural part of aging; however, it does become more common as individuals become older. If urine incontinence is interfering with their everyday activities, I would consider it as a key point of defect that needs much attention. Symptoms of urine incontinence may usually be treated with easy lifestyle and dietary modifications, as well as medical attention.
Other Objective Findings I Would Look For
Comprehensive background and detailed examination are required for all patients who present with genitourinary complaints. Genitourinary scanning should not be used to substitute clinical skills that lead to a probable diagnosis and perhaps many differential diagnoses (Espay et al., 2018). These are the ones that direct the practitioner to the right tests, provided at the right time. Symptoms should be evaluated in consideration of the patient’s clinical, surgical, and gynaecological background, along with obstetric history, family medical history, sexual experience, including overall and particular risk factors (Jones, Pietrzyk, Cristea, & Whitson, 2019). Keeping in mind that symptoms that appear to be related to the genitourinary system can sometimes be transmitted from elsewhere; for example, urine symptoms might be caused by psychological issues, metabolic, or neurological. Furthermore, symptoms that appear to be related to many other systems may even be caused by genitourinary disorders.
Diagnostic Exams to Order
First, without subjecting the patient to ionizing radiation, ultrasonography can give valuable radiographs of numerous genitourinary organs. Images will be analyzed as they are received, allowing the specialist to concentrate on challenging regions and get extra information as needed (Jones et al., 2019). Its primary drawbacks are the necessity for a trained operator as well as the amount of time it takes to complete (Espay et al., 2018). Although a full bladder aids in the visualization of some structures, no further preparation is required. Therefore, this would be the first diagnostic exam to order for the patient with consideration of a full bladder to assist in the visualization of relevant structures to be examined.
Second, it would be important to consider that the urinary system and its surrounding tissues may also be seen in great detail using computed tomography. In this case, it would be essential without IV contrast agents in determining the stone composition. For the most part, conventional or helical scanning machines will be utilized, both with and without IV contrast agents (Espay et al., 2018). When contrast agents are being used with either approach, it is similar to IV urography (IVU), but it offers more data. Originally, there was worry that using contrast in trauma patients might make it impossible to discern between abdominal bleeding and urinary tract damage, however, this difference can now be achieved using such contemporary imaging practices and approaches. For scanning calculi, helical CT without contrast seems to be the preferred method; dual-energy scanners may offer extra information that could still aid in determining stone composition.
Three Differential Diagnoses Based on The Patient Presenting Symptoms
Pathophysiology and Differential Diagnosis
Differential diagnosis, or perhaps the development of a list of potential diseases, is critical because it directs my investigation for these diseases in such a patient upon diagnosis. A cystoscopy is a procedure in which I examine the bladder using a tiny tube with the use of a camera and light connected (Garel, Blondiaux, Della, Guilbaud, Khachab, Jouannic, & Garel, 2020). If necessary, I can even use the cystoscope to take a sample of bladder tissue. A biopsy is a tiny sa
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