Joan is a 35-year-old woman who presents with a complaint of headaches that have been occurring more frequently over the last 2 weeks. She has never had any problems with headaches before. Rarely, she has had a headache after a stressful day but denies premenstrual headaches or frequent headaches until 2 weeks ago. Her headaches are left sided in the temporal area and are severe (7 out of 10 on a scale of 1–10) and throbbing. They occur 3–5 times each week. She occasionally becomes nauseous but rarely vomits. The headaches tend to last several hours and go away if she is able to get sleep. Joan tries to retreat to a dark and quiet corner when the headaches begin. She sometimes sees “spots in front of her eyes” right before the onset of a headache. Otherwise, she has no trouble with her vision, has had no epistaxis, upper respiratory symptoms, or sinus symptoms. She denies trauma to her head or any neck stiffness. She denies fever, chills, numbness, or weakness.
Past Medical History: Besides the headaches, Joan has been well and denies any previous surgeries or hospitalizations other than for 3 uncomplicated vaginal deliveries.
Family History: Migraine headaches in her mother and sister. Her uncle had a benign brain tumor that has been successfully treated.
Social History: The patient does not smoke, drinks 1 beer 3 times each week, and denies ever using recreational drugs. She is married and works as an administrative assistant in a busy office. She has 1 preteen and 2 teenagers at home. Their behaviors sometimes cause her to have some stress. Her husband is supportive and helpful.
Medications: Joan’s medications include occasional ibuprofen for “aches and pains.” She tried the ibuprofen for the headaches without relief. She takes no other medications. She states that her mother told her that she was allergic to penicillin as a child, but does not know why.
Objective
General: Joan is well groomed. Her manner and speech are appropriate and she is articulate. She is in no apparent distress during this visit.
Vital Signs: The patient is afebrile, B/P 140/90 (which is higher than normal), pulse 86, resp 12.
HEENT: Head atraumatic and normocephalic. PERRLA, sclera clear, conjunctiva without injections. EOM’s intact. No AV nicking or papilledema. Optic disks have clear margins. Nasal mucosa is without erythema or drainage. There is no sinus tenderness to palpation. Cranial nerves II-XII are grossly intact
Cardiac: Unremarkable
Neurological: Sensation and proprioception are grossly intact and the Romberg test is negative. Gait is steady. Brudzinski and Kernig signs are negative.
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Assignment Requirements
The finished Assignment should be a care plan, encompassing all required items listed. The viewpoint and purpose of this Assignment should be clearly established and sustained.
