NURS 6512 Week 9 Case 1 Headaches COMPLETE LATEST UPDATE 2024

Case 1: Headaches A 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. Patient Information: S.O., 49 , Male, Asian S. CC Headache HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Location: head, pain all over, pain is worse with pressure on the forehead, the nose, cheekbones, and jaw. Onset: Intermittent for two months, more frequent one week. Character: pounding dull ache with pressure Associated signs and symptoms: nausea, photophobia, phonophobia Timing: onset varies in time but most frequently in the evening after work. Exacerbating/ relieving factors: cool rag on forehead helps slightly, light, and noise make it worse. Severity: 8/10 pain scale Current Medications: Fluticasone Propionate Nasal Spray 50 mcg sprayed in each nostril once daily for season allergies. OTC Acetaminophen 500 mg PO every 6 hours for pain. Allergies: Latex, rash. Strawberries, rash. PMHx: Appendectomy age 10 years old, L4-L5 lumbar spinal fusion 2008 and T2-T3 cervical spinal fusion 2010 both for degenerative disk disease. Tetanus vaccine 2007. Flu vaccine October 2017, reports up to date on all other vaccines. Soc Hx: Accountant and competitive dart thrower. Single, heterosexual, denies current sexual partner, states he has no interest in “dating” at this time. Denies smoking, exposed to second hand smoke at Dart competitions. Denies alcohol intake. Reports seat belt use while driving, denies guns in home, lives alone. Reports several caffeinated beverages daily, 3 cups coffee and soda. Fam Hx: Father living age 81, coronary artery disease, HTN, and skin cancer unknown type, Mother diseased age 71 breast cancer, Grandparents all diseased unknown health history, One sibling, living, brother age 55, CVA. ROS: GENERAL: Denies recent illness, weight loss or gain, denies any fevers, chills, or night sweats. HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae, states that eyes are very sensitive to light during headaches. Ears: denies pain, discharge, or hearing changes. Nose: reports seasonal rhinorrhea, reports pain during headaches in sinus area, Throat: Denies pain, denies difficulty speaking or swallowing. SKIN: Denies any open wounds, sores, lesions, rash, or bruising. CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations and edema. RESPIRATORY: Denies shortness of breath, cough. GASTROINTESTINAL: Reports anorexia with headaches, nausea, and vomiting. GENITOURINARY: Denies burning on urination, increased frequency, or nocturea. NEUROLOGICAL: Intermittent headaches, denies dizziness, denies syncope, denies paralysis, ataxia, numbness or tingling in the extremities. Denies changes in bowel or bladder control. MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain or stiffness. HEMATOLOGIC: Denies bleeding of gums, denies frequent bruising. LYMPHATICS: Denies enlarged nodes. PSYCHIATRIC: Reports history of depression and anxiety, has never sought treatment. Reports good mood recently. ENDOCRINOLOGIC: Denies excessive thirst, hunger, or need to urinate. ALLERGIES: Seasonal allergies with Rhinorrhea and sneezing, treated with nasal spray. Strawberries and Latex produce rash response.