Professional Nursing Clinical

Bates’ Physical Exam Case #13

David is a 21-year-old college student who comes into the provider’s office with a complaint of headache.

As you watch this encounter, you will be asked to answer questions while the image on the screen freezes. These questions will engage you in practicing the skills of focused history taking, physical examination, and clinical reasoning as you develop your preliminary differential diagnosis.


You are expected to develop three diagnoses with supporting history and physical examination findings, and to list the diagnostic workup studies you would order.


You will have time to record your findings and receive feedback. You may go back to review the video again.

What are 3 potential diagnoses? Explain your rationale to support each diagnosis.  












What symptoms does he offer?  








Summarize how David describes his headache.  







What other associated symptoms does he report?  










David’s vital signs are:

BP 100/60

HR 100

RR 20

T 99.1


Are any of these vital signs abnormal or concerning? If so, why? If not, why not?


What areas of the assessment are important to complete at this time?  











What abnormal assessment findings are identified?  








Describe the Babinski reflex. Why is this important?  








Describe the Brudzinski sign. Why is this important? What does a positive sign indicate?  







Describe the Kernig sign. Why is this important? What does a positive sign indicate?  






Now that you have obtained information and completed the assessment on David, what are 3 potential diagnoses? List in order of priority and give your rationale.  






















What are 3 diagnostic studies you will complete? List in order of priority. What is the purpose of each diagnostic study?