Case study in advanced pathophysiology

CASE STUDY NO. 1
Patient is a 38 yr. old female who is new to the physician office today the patient comes in with complaint of the following:
Patient states is new to the practice and her primary complaint today is headaches, right temporal/jaw pain, and ear pain. She states she has had this headache for the last week and has headaches often. She takes Advil or Tylenol up to 4x weekly approximately 800 mg of Advil alternating with 1000 mg of Tylenol. she works nights and cares for a small child who is 5 years old.
Headaches have been more frequently, and seem to last approximately 6 hours. she has tried cold compresses, and sometimes they affect her vision as well. She chews gum at night while at work so she does not eat as much . She has a PMH of tonsillectomy and adenoidectomy at age 6 and endometriosis diagnosed 2 years ago. Family Medical hx father is 82, with aarthritis, mother is deceased at age 71 from a heart attack and she has a brother who is 42 who has heart disease.
She works nights at the Gas station and mini mart and states she does not always have time to eat “healthy” nor the money. Her VS for you today are 132/88 hr 89, r18 T. 97.6 and BMI is 42.
She has No Known Drug Allergies.
FOR THIS CASE STUDY, DO NOT ADD TO THE SCENARIO. ANSWER THE FOLLOWING QUESTIONS:
FORMAT:
(Case Study Format:
Here is a “general” format;
Title page/Page numbers
Case Presentation
Pathophysiology of the (illness )
Your Physical Assessment -What are you going to assess and why
Differential Diagnosis- what could it be, Evidence Based Practice -Rationale, support with EBP
Cultural Perspectives
Health Promotion – what would you teach the patient?
Treatments- both pharmacological and non pharmacological
(Include CYP 450 system)
What tests, screenings might you consider
What is your Plan of care, when would you have them f/u with provider and why?
References 3-5- All these items – you need to support with Evidence Based Practice, such as for example, Non pharmacological interventions- where did you obtain your info, citation for the source; any tests, any of the above items, support your rationale with Evidence Based Practice.
Case studies will be presented in 2, 3 or 4 body systems. The student will develop a Differential Diagnoses for each case study based on the information provided, and document their clinical reasoning in deciding on a final diagnosis The student will document the steps taken in the decision process, additional or missing data, the decision rationale, proposed treatment plan and follow up plan for assessment of treatment plan success. In addition, include cultural considerations, References Minimum 3 to 5 Peer Reviewed Journals outside of the class materials within 5 years. APA 7th ed.
I have attached a rubric to this assignment. Please make sure that at least 3 sources are from peer reviewed jounals

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