Case: Beth Brown Date: February 13, 2022
I-HUMAN Case Study #2: Beth Brown NURS 5308 Midwifery 1 April 7, 2022
CC: 16 y/o F
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
“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.
Case: Beth Brown Date: February 13, 2022 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
FamHx Grandparents (if known)/Parents/siblings/children
SHx
None
Case: Beth Brown Date: February 13, 2022 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:
Case: Beth Brown Date: February 13, 2022 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
Case: Beth Brown Date: February 13, 2022 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 Psych: Denies anxiety, depression, loss of energy or changes in interests
Physical Exam: (PE) Use this column to document the PE below. Height: 5' 6" (168.0 cm) Weight: 122 lb (55.0 kg) (BMI 19.7) Temperature: 98.6 F (oral) Pulse: 74 bpm - regular Blood pressure: 118/68 mmHg - supine/sitting Blood pressure: 116/62 mmHg - upon standing Respiratory rate: 12 bpm SpO2: 99% on room air General: Thin, pleasant, cooperative female, alert and oriented x4 Skin/Breast: Warm, dry and intact, no redness, lesions, or bumps noted Breasts: Deferred Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge. No orbital edema, redness, tenderness Ears: Pinna and tragus without tenderness upon manipulation bilaterally. Canals are clear bilaterally, tympanic membrane pearly, translucent, and pinkish-gray in color with intact landmarks bilaterally Nose: Nares patent bilaterally, no nasal drainage or polyps, septum midline and intact, no edema or tenderness over frontal or maxillary sinuses, Sinuses non-tender to light percussion, no temporal artery tenderness
From the PE: list/highlight the presence or absence of objective findings to generate a list of pertinent “(+) or (-)” symptoms below: Pertinent (-) Eyes: Lashes without crusting, eyelids without edema, erythema. Conjunctivae pink, no discharge. No orbital edema, redness, tenderness Nose: Nares patent bilaterally, no nasal drainage or polyps, septum midline and intact, no edema or tenderness over frontal or maxillary sinuses, Sinuses non-tender to light percussion, no temporal artery tendernes Neck: No visible scars, deformities, or lesions, the trachea is midline and mobile, no cervical mass or regional lymphadenopathy, full cervical-spine ROM
Neuro: CN II-XII grossly intact, normal gait and posture, no involuntary movements noted patellar and brachial reflexes 2+ bilaterally, no facial asymmetry MSK: No tenderness, muscular resistance, rigidity, asymmetry, or deformity noted, ROM is equal bilaterally on upper and lower extremities