SAMPLECASE分析.docVIP

SAMPLE CASE Boston University School of Medicine Clinical Skills Center Author’s Name: Lorraine Stanfield, M.D., BUSM Date ____3/07 Clerkship: EOTYA Anticipated Time: 15 minutes for focused H P OUTLINE FOR FOCUSED PROBLEMS Short Case Title: Woman with Headaches (Students: Note this is the patient’s “script”. You would only see the “Opening Scenario” on page four, and the write-up form on page 10.) Laura Jackson, a 39-year-old woman, presents to a primary care center for evaluation of headaches Ms. Jackson, who works as an accountant, has been noticing worsening headaches over the past month. At first she only noticed them late in the day after she had been working on the computer for many hours. Now she has difficulty seeing the computer screen earlier in her work day, and often has a headache late in the day. Distancing herself from the screen seems to help the blurriness somewhat, but then the numbers seem very small. In general the headache is felt as a pressure across her forehead. Tylenol usually helps resolve it. The typical pain is described as a 4-5/10 on the pain scale, lasts an hour, and occurs 2-3 days/week. Yesterday she had a more severe headache after work that went up to 7/10 and lasted for several hours. She felt nauseated but did not vomit. The only thing that helped was going to bed. Now she has a mild headache. She has good energy and denies change in weight, polyuria, polydyspia, vomiting, muscle weakness or numbness. She felt a little warm yesterday during the headache, but does not own a thermometer and did not take her temperature. Some colleagues at work have had colds and she is starting to get a stuffy nose and her neck feels sore. She has not been to see an eye doctor in about 8 years, and never wore glasses. She has been drinking more coffee than usual. She denies floaters or visual scotomata. She has had very heavy periods for the past six months. Social History: Ms. Jackson has been under some stress at work recent