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1.

痛みの性状. 視力障害・平衡障害・錯乱・嗜眠はあるか. 発熱あるか. 眼痛はあるか. 複視はあるか. 麻痺はあるか. 頭痛の発症はいつからか (何歳からか). 前兆はあるか. これまでの頭痛と違うところがあるか. 頻度はどのくらいか. 痛む部位. 随伴する特徴. 悪化要因や緩和要因. 経時的変化.

2.

次の予約を入れる. 息子も連れて来るように言う. 育児・しつけについて相談できる機関 (児童相談所など) を紹介.

Faculty Comments

You explain the headaches she describes are consistent with muscle contraction, or "tension" headaches. Your recommendations include keeping a headache journal and using acetaminophen 650mg every 4-6 hours PRN. You also encourage the patient to identify additional areas of stress in her life, while trying to participate in light exercise a few times a week to help reduce stress.

You also suggest the patient talk with school guidance counselor regarding her son's school behavior and academic issues.

Lastly, you have Mrs. Miller schedule her annual physical for next month, with plans to follow-up on her headaches and stress level at that time.

3.

乳癌・子宮癌検診

Faculty Comments

A complete physical exam, including a gynecological exam (clinical breast and pelvic exams and pap smear). The patient should be educated on breast self-exams.

Immunizations should be reviewed and updated (tetanus and influenza). Due to the patient's hypothyroidism and use of Synthroid, a TSH and T4 should be checked every six months.

Cholesterol levels within the desired range (in this case <200mg/dL) do not need to be checked more frequently than every three years.

4.

Faculty Comments

Diet - A low fat, high fiber diet, with at least 1200 mg/day of elemental calcium should be encouraged.

Exercise - You encourage Mrs. Miller to participate in a minimum of 20 minutes of aerobic exercise three times per week. You also discuss the importance of strength building/resistance exercises to help maintain optimal bone density.

Substance Use- Mrs. Miller denies the use of tobacco products and illicit drugs. She drinks one to two glasses of red wine each night to help her "fall asleep".

Safety - Seat belt use is reviewed, as is the presence of smoke detectors in the home and the use of helmets when bicycling.

Domestic violence - When Mrs. Miller is asked if she feels safe in her home, her eyes quickly focus on the floor.

5.

家庭内暴力の存在が疑われる (家庭で安心できるかという問に答えなかったこと, 両側膝点状出血の既往などから).

Faculty Comments

Mrs. Miller has many features suggestive of domestic abuse: