IHUMAN Case Study
NURS 5308 Midwifery 1
(NURSE JOLLY)
IHUMAN Case Study #2: Beth Brown
NURS 5308 Midwifery 1
2021
CC: 16 y/o F
HPI: pertinent s/s; +/- ROS/prior episodes/recent travel/ill contacts
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(solved) IHUMAN Case Study #2 Beth Brown NURS 5308 Midwifery, Exams of Nursing
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IHUMAN Case Study
NURS 5308 Midwifery 1
(NURSE JOLLY)
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
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 G0P 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
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
Date: February 13, 2021
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 x 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
Date: February 13, 2021
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, Tylenol or Advil. 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. Upon examination there were no neurological changes noted, physical exam was unremarkable with no pertinent positives supporting her complaints. List the differential diagnoses (Must not Miss/Leading/Alternate/Concluding – total of 3 _Include ICD 10 codes after each_*
**1. Migraines G43.909 LEADING (MUST NOT MISS, if one had to be selected)
- Tension headache G44.209. ALTERNATE
- Cluster headache G44.0. ALTERNATE Plan** No lab or diagnostic workup necessary at this time Medication options: Acetaminophen PO 325 - 650 mg q4- 6 hours, NSAIDS or aspirin
Date: February 13, 2021
Anti-nausea medication as needed such as Zofran, or Reglan Indomethacin PO 25-50 mg tid or qid (max 200 mg/day) Sumatriptan PO 25 mg Dihydroergotamine intranasal 1 spray (0.5mg) in each nostril, repeat with additional spray 15 min if no relief (max 4 sprays per attack), wait 6-8 hours before treating another attack Propanolol 80 mg/day PO Verapamil 80 mg PO q 6 - 8 hours Lisinopril 5-40 mg day PO Valproic Acid 250 mg BID PO Plan and Education: Avoid chocolate, caffeine, alcohol, smoke which are migraine triggers Rest Ice applied to the back of the neck Hot showers Reduce stress by yoga, meditation, biofeedback, CBT, massage therapy
Date: February 13, 2021
Reflective Thinking Exercises
Instructions: Review the Case summary of your IHUMAN case, noting strengths and areas of needed
improvement. Answer the following questions below in brief essay format. Essay should be no longer than 1 - 1.
pages in APA format in length. Points will be assigned as to the quality/depth of the student’s reflection.
Date: February 13, 2021
1. History-Taking: Describe your history taking scores and strengths you identified when gathering data. What
went well? Also, describe your challenges in gathering data and list areas of your personal needed
improvement. Note any missed areas that could be safety issues/errors leading to missed or incorrect
diagnosis.
My history taking for this case were improved because I am more knowledgeable regarding headaches, types
of headaches and causes. I was able to ask all the necessary questions because I used a more structured
approach focusing on the chief complaint. Using OLDCARTS to ask the patient questions guided me to all
the needed information to rule in and rule out diagnosis. I had to maintain a balance between asking history
questions and OLDCARTS for the chief complaint. That is always a challenge for me as it can take me off
track. I had more confidence with this case and a better outcome/score.
2. Physical Exam: Describe your physical exam scores and strengths you identified when performing selected
exams on your patient. Did you perform an excessive amount of exam items? Did you miss any pertinent
exam items identified in the case leading to diagnosis? Note any missed areas that could be safety
issues/errors leading to missed or incorrect diagnosis.
In the physical exam portion, I focused on the systems I thought were relative to diagnosing headaches.
These systems consisted of ENT, Neck, Neuro, and MSK. I was looking for information regarding sinuses
Date: February 13, 2021
complaints, continue to go through OLDCARTS and being self-aware of my areas of improvement.
Repetition of patient encounters, PEN notes, and study of systems my skills and confidence will continue to
improve.
References Cluster headache - Symptoms and causes. (2019, June 4). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cluster- headache/symptoms-causes/syc- 20352080
Date: February 13, 2021
Migraine - Symptoms and causes. (2020, January 16). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/migraine- headache/symptoms-causes/syc- 20360201 Migraine. (2002, March 27). WebMD. https://www.webmd.com/migraines-headaches/migraines-headaches-migraines Tension headache - Symptoms and causes. (2019, June 11). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/tension- headache/symptoms-causes/syc- 20353977 Tension headache: MedlinePlus medical encyclopedia. (n.d.). MedlinePlus - Health Information from the National Library of Medicine. https://medlineplus.gov/ency/article/000797.htm UpToDate. (n.d.). https://www.uptodate.com/contents/cluster-headache-epidemiology-clinical-features-and-diagnosis