*NURSING > iHuman > IHUMAN Case Study 2 Beth Brown NURS 5308 Midwifery 1 Latest 2021 (All)

IHUMAN Case Study 2 Beth Brown NURS 5308 Midwifery 1 Latest 2021

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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 headach... es 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 ......................................................continued [Show More]

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