NU610 Unit 1 Case Study: A 19-year-old female presents with a complaint

NU610 Unit 1 Case Study

A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had them since she was a teenager, but they have become more debilitating recently. The episodes occur once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain including loud noises and movement. She has taken several over the counter medication like naproxen and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet room. Reports no drug allergies but has seasonal and allergies to pet dander.  A thorough history reveals her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms.  Currently a freshman in college.  

Denies alcohol, illicit drug and tobacco use.  Last health visit was over the Summer, up to date on health maintenance for her age.  She denies fever, chills, night sweats or neck stiffness.  She denies visual changes other than photophobia.  She denies chest pain, palpitations, shortness of breath or cough.  She denies abdominal pain, has some nausea with the headaches but no vomiting.  Denies numbness, tingling, weakness or changes in mood.  Vital signs: temperature 98.5, BP 112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs.  Alert and oriented to self, place, time and situation.  Appears stated age with skin warm and dry.  Normocephalic, PERRL, TM gray with adequate conf of light bilaterally, no tenderness over sinuses.  Mucous membranes pink and dry.  No palpable masses, adenopathy or thyroid enlargement.  Regular heart rate and rhythm without murmurs. No edema.  Lungs clear bilaterally, no use of accessory muscles.  Soft, non-tender, non-distended abdomen with normoactive bowel sounds.

Normal visual acuity using Snellen chart 20/20, face symmetrical with symmetrical smile and puffing out cheeks.  Weber and Rinne test performed with normal bone and air conduction.  Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt. says “ah.” Positive gag reflex.  Shrug shoulders spontaneously and against resistance, hypoglossal nerve intact. Muscle tone inspected, palpated without atrophy and strength 5/5.  Bicep, patellar and Achilles reflexes 2+ bilaterally with negative Babinski.  Able to distinguish light and deep touch.  Able to complete heel to shin, gait steady.