Sally Jones, 45 years old, presents to the primary care clinic with complaint of a headache. She says the headache usually comes when she is a work. She works as an administrative assistant for a Chief Financial Officer at a local hospital. The headache is usually generalized and bilateral and most of the intensity of pain is around the neck or the back of her head. Sally says “When the pain comes it is like a tight band around my head.” She says the headaches have been occurring more frequently over the past 30 days.
Based on the case study provide a response to each of the following questions.
1 Based on this case study, describe the focused physical assessment you will perform on this patient.
2 Provide rationale for conducting the focused assessment and support with peer-reviewed scholarly references.
3 Identify the diagnostic studies/tests you will order for this patient (if any).
4 Provide scientific, evidence-based rationale from a nationally accepted clinical guideline to justify the diagnostic studies/tests you will order for this patient.
5 Provide an estimate of the cost of the diagnostic studies/tests you decide to order for this patient.
6 Develop a comprehensive, holistic treatment plan including pharmacologic and non-pharmacologic therapies for this patient.
7 Provide the patient education you will provide to the patient prior to them leaving the clinic during this visit.
8 Be certain to include a return appointment date as to when the patient is to return for follow up and evaluation.
9 Be certain to advise the patient of actions to take if her symptoms should worsen in any way prior to her return follow-up evaluation visit to the clinic.