IHUMAN Case Study - NURS 5308 Midwifery 1 CC: 16 y/o F HPI: pertin...

IHUMAN Case Study

IHUMAN Case Study #2: Beth Brown

NURS 5308 Midwifery 1

CC: 16 y/o F HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts

Case: Beth Brown

Date: February 13, 2021

“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

Case: Beth Brown

Date: February 13, 2021

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, 2021

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