Informatic Cancer Case Study

Identifying Data: R.S. is a 28 year old Indian female of Indian-American of Asian descent. She is a full time nursing student currently residing in Rochester. She is single and does not have children. Patient presents today complaining of pressure headaches and is alone.

Source Reliability: Patient herself, who appears reliable provided history, which is confirmed by her provision of the same answers, even when questions are rephrased or repeated later in interview.

S: Chief Complaint: “pressure right over eyebrows” HPI (8 Dimensions):
Patient reports throbbing pressure over the eyebrows that have developed over the past 3 weeks, worst while walking home in the evenings from practical section of nursing school. Reports no other changes

Patient reports tenderness when frontal sinuses palpated. Temporal arteries elastic and nontender. Temporal arteries pulse +2. Temporomandibular joint palpated with full range of motion without tenderness or clicking.
Face:
Symmetric, no drooping, no weakness, no involuntary movements
Scalp:
Hair is distributed evenly with thick texture and no balding.

Nose and Sinuses:
Nasal septum midline. Turbinates do not appear swollen. Mucosa appears pink and moist. Congestion in left nostril noted. Odor identification and sense of smell symmetrical. Frontal and maxillary sinuses are nontender to palpation.

Eyes: Conjunctiva clear and pink, no redness. Sclera white. Corneal smoothness and clarity noted. Snellen chart visual acuity 20/15 bilaterally. Complete and symmetrical red circle noted in both eyes. Ocular alignment noted, assessed by cover-uncover test. Intact peripheral field of vision, demonstrated by confrontation test results: 50 degrees upward, 90 degrees temporally, 70 degrees inferiorly, and 60 degrees nasally. Conjugate vision, no deviation noted during extraocular movement. Both pupils equal, round and reactive to light and