Patient Assessment Essay

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Mack Ervin, Jr. Prof. Marcia McCormick Biopsychology Tues 7-10pm 11/30/11 Patient Assessment A 39 year old female patient presented in the doctor’s office with the following symptoms: Headaches, insomnia, rapid thoughts, dizziness, and a lack of motivation. The patient initially said her symptoms began approximately 2 months ago and have been fairly persistent. While she is in some discomfort, she does not appear to be in immediate danger: All of the patients’ vital signs were within normal range. In an attempt to make a preliminary diagnosis I began to ask questions about her condition. I wanted to address each of her symptoms and try to find causation. Her most obvious symptom was the headache. I asked if she had recently been struck in the head, fallen and hit her head, or had some recent accident that involved an injury to the head. The patient said she suffered no recent head trauma. After a physical examination of the patients head, I concluded that there were no visible signs of a head injury. Although she stated that she had not recently suffered a head injury, I needed to inquire about past injuries. After some prodding, the patient revealed that as a child she fell off of the monkey bars and hit her head. Since then, she has had headaches intermittently. My initial diagnosis is that of migraines brought about by a head injury. I will order an MRI to check for any abnormalities or scarring on the brain from the possible childhood injury, or even a recent fall that she does not remember. I am choosing an MRI rather than a CT scan, because if a doctor’s initial evaluations reveal a skull fracture or intracranial bleeding, then a CT scan is usually ordered. CT stands for Computerized Tomography; it is a relatively quick a way to obtain detailed X-ray pictures of cross-sections of the brain. The test is quick and results come back fast, thus making it

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