PBL 5 session 2

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PBL 5 session 2 by Mind Map: PBL 5 session 2

1. Step 8

1.1. Diagnostic decision

1.1.1. hemipligic migraine

1.2. Mechanism

1.2.1. multifactorial with possible genatic influence and life stresses

1.3. Presentation

1.3.1. 3 episods of throbing left side headache with aura( zig-zag visual pattern), sensory and motor abnormalities

1.4. Supporting data

1.4.1. HISTORY

1.4.2. and exclusion of other possibilities

1.5. 10 minutes

2. Step 6

2.1. Review session 1

2.2. Report new knowledge

2.2.1. headache

2.2.1.1. types

2.2.1.1.1. migraine

2.2.1.2. pathophysiology

2.2.1.3. etiology

2.2.1.4. clinical presentation

2.2.2. aura

2.2.2.1. types

2.2.2.2. why does it happen

2.3. 30 minutes

2.3.1. The scribe does not have to write in this step!

3. Step 7

3.1. Inquiry plan and info gathering

3.1.1. History of presenting complain

3.1.1.1. left side headache

3.1.1.2. headache started from the past 2 weeks as episode

3.1.1.2.1. 3 episods

3.1.1.3. headache last for four hours

3.1.1.4. moderitly to sever throbing pain

3.1.1.5. there is nousia vomiting and photophobia

3.1.1.5.1. ZIG-ZAG pattern in the left side

3.1.1.6. the pain come after the aura

3.1.1.7. she take 900 mg of aspirin to reileve pain

3.1.2. Previous medical / surgical history

3.1.2.1. she have a history of migraine

3.1.2.1.1. stress was the main trigger

3.1.2.1.2. frequently

3.1.2.2. she has been migraine free for several years

3.1.2.3. she had aura ( in the past )

3.1.2.3.1. visual symptoms in both visual field which last for 30 min

3.1.3. Drug history / allergy

3.1.3.1. she take 900 mg of aspirin to reileve pain

3.1.3.2. triphasic oral contrasiptive pills for the last 15 years

3.1.4. Family history

3.1.4.1. the mother has history of headache with photophobia

3.1.5. Social / occupational history

3.1.5.1. teacher / musician

3.1.5.2. non-smoker

3.1.5.3. no children

3.1.5.4. stress at work last 2 month

3.1.5.5. missed couple of classes because of headache

3.1.6. Systemic review

3.1.7. Physical examination

3.1.7.1. vitals

3.1.7.1.1. BP 110/70

3.1.7.1.2. PULSE 76

3.1.7.2. right handed

3.1.7.3. cranial nerve examination

3.1.7.3.1. visual acuity 6/5 in both eyes with her glasses

3.1.7.4. neurological limp examination

3.1.7.4.1. normal

3.1.7.5. deep tendon reflex are normal with downgoing planter responses

3.1.8. tests results

3.1.8.1. FBC

3.1.8.1.1. NORMAL

3.1.8.2. electrolight normal

3.1.8.3. lupos anticogulant is normal

3.2. 50 minutes