IHUMAN Case Study #2: Beth Brown NURS 5308 Midwifery 1 Instructor: Tania Lopez March 5, 2021

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Julie Quinn IHUMAN Case Study #2: Beth Brown NURS 5308 Midwifery 1 Instructor: Tania Lopez March 5, 2021 CC: 16 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill cont... acts “I have worsening severe headaches”. Ms. Brown, 16 y/o female presenting with more frequent, severe headaches start started 10-12 weeks ago, occurring every week. The headache presents unilaterally on the left side of the head and is felt behind the eye. Pain is rated 8-10/10 and prevents the patient from doing any activities, and sometimes the pain last up to 15 hours. She says she has a sensitivity to light, loud noises, nausea, and vomiting. The intense throbbing headache usually happens when there isn't enough sleep or after eating junk food and chocolate with friends. She states before the headache there are visual distortions like "thin veils" at the edges. The headaches are relieved by a dark room and sleep. She also has a less severe secondary headache described as "band-like" involving the entire head, neck, and shoulders that is relieved by hot showers. She believes the secondary headache is due to her position when studying. Her mom has a history of headaches. PMHx child/adult illness/hospitalizations/immunizations No medical issues No prior surgery No OB/GYN issues - menstruation is regular and no issues G0P0 Wears helmet when biking Plays sports - soccer Nutrition: “regular American diet”; tries to minimize junk food Immunizations: Up to Date except HPV, first dose of meningococcal at age 12, Tdap at age 12 SurgHx None FamHx Grandparents (if known)/Parents/siblings/children SHx Father: Unknown Mother: Longstanding headaches Siblings: None Spouse/offspring: N/A Tobacco/vaping/ETOH/illicit drug use/occupational/environmental/relationships Lives with mother in single parent home Housing: single-occupancy apartment Student: gets straight "As" Substance use: no smoking, no alcohol, no recreational drugs Denies being sexually active Reproductive Hx Female: Menarche unknown dates Last period 2 weeks ago Not sexually active Allergies (Food, Drug, Environmental, etc) NKA List of Current Medications/supplements (prescription, OTC, complementary alternative therapies) Acetaminophen or Advil PRN for headaches Excedrin as needed Benadryl PRN for sleep Review of Systems: (ROS) Use this column to document the ROS below. General: Denies any problems with fatigue, difficulty sleeping unintentional weight loss or gain, and night sweats Skin/Breasts: Denies any problems with itchy dry scalp, skin changes, moles, thinning hair, or brittle nails From the ROS: list/highlight the current symptoms/complaints to generate a list of pertinent “reported or denied” symptoms below: Denies any breast discharge, lumps, scaly nipples, pain swelling, or redness Eyes: States "visual distortions, blurry wiggly stuff at the edges of eyes, like a "thin veil" ENT: Denies any drainage, swelling, redness Pulmonary: Denies SOB at night or at rest or when lying down, denies cough, wheezing or difficulty catching breath, chronic cough or sputum production CV: Denies palpitations, pain or discomfort, heavy feeling or sensation of a “pounding heart GI: Denies constipation, or heartburn. States normal bowel movements, states nausea, and vomited once with headache GU: Denies pain, burning, blood in urine, denies difficulty starting or stopping urinating, dribbling, incontinence, urgency during night or day, or any changes in the frequency of urination MS: Denies muscle weakness, joint pain, stiffness, redness or swelling Heme: Denies bruising, bleeding gums, nose bleeds, abnormal bleeding, or history of anemia Endocrine: Denies heat and cold intolerance, increased thirst, increased sweating, frequent urination, or changes in appetite Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness. States "more frequent, severe headaches start started 10-12 weeks ago, occurring every week", headache presents unilaterally on the left side of the head and is felt behind the eye, pain is rated 8-10/10 . She says she has a sensitivity to light, loud noises, nausea, and vomiting. She states before the headache there are Eyes: States "visual distortions, blurry wiggly stuff at the edges of eyes, like a "thin veil" GI: Denies constipation, or heartburn. States normal bowel movements, states nausea, and vomited once with headache Neuro: Denies dizziness, lightheadedness, fainting, room spinning, seizures, or weakness. States "more frequent, severe headaches start started 10-12 weeks ago, occurring every week", headache presents unilaterally on the left side of the head and is felt behind the eye, pain is rated 8-10/10. She says she has a sensitivity to light, loud noises, nausea, and vomiting. She states before the headache there are visual distortions like "thin veils" at the edges. She also has a less severe secondary headache described as "band-like" involving the entire head, neck, and shoulders ..............................................................................continued..................................................................................................... [Show More]

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