NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning INITIAL POST Case Study #3 Patient Initials: _JS__ Age: __20___ Gender: _M__ SUBJECTIVE DATA: Chief Complaint (CC): Headache History of Present Illness (HPI): JS is a 20 year old Caucasian male who was in his usual state of health until about 4 weeks ago and presents today with complaints of experiencing intermittent, pressure headaches. He states that the headaches diffuse all over the head, but the greatest intensity of pressing and tightening occurs above the eyes and spreads through the nose, cheekbones, and jaw. The duration of the headaches vary but seem to last longer after a long day at work. JS describes the headache as mild at first but builds with intensity and is bilateral in nature. JS states that he does not experience nausea or vomiting with the headaches but does have a hard time concentrating and experiences insomnia from time to time due to the headaches. He states that he feels that the muscles in his neck, occipital and frontal regions become tight. He takes Tylenol or ibuprofen for the headaches which generally work unless he waits too long then it takes longer to be effective. JS noticed that the headaches started to occur after beginning work at a second job and became more frequent when he worked longer hours. He noticed that he rarely had headaches on the weekends when he wasn’t working. JS states that his pain level can be as high as 7/10 with an intense headache. Medications: Ibuprofen 200 mg oral tab, three tabs every 6 hours as needed for headache. Tylenol 500 mg oral tabs, two tabs every 6 hours as needed for headache. Allergies: No known drug, food, or environmental allergies. Past Medical History (PMH): Hairline fracture of right wrist in 2011. Past Surgical History (PSH): None Sexual/Reproductive History: JS is sexually active but not currently in a relationship. Patient states he uses condoms with intercourse. Patient states that he has had 3 partners in his lifetime and denies any history of STDs. Personal/Social History: Patient denies smoking and illicit drug use. The patient states that he occasionally drinks 3-4 alcoholic beverages on the weekends. The patient is very active, goes to the gym at least 3 times a week and plays ultimate Frisbee at least two evenings a week. Recently he has had to cut back on exercise do to the time commitment of starting a second job. JS often hangs out with his friends on the weekends unless he has an extra painting job or shift at the restaurant. Immunization History: Immunizations are up to date. Gets the flu vaccine routinely every year. Significant Family History: Father is healthy with no known issues. Mother recently diagnosed with breast cancer and in the middle of treatment. Paternal grandmother has hypertension. Maternal grandmother has rheumatoid arthritis. Lifestyle: JS is a junior in college who lives off campus with 3 other roommates. JS plays ultimate Frisbee and tries to exercise regularly but has had to cut back recently. JS works part time at a restaurant and recently starting working a second part time job with a painting company approximately 6 weeks ago. He has been working long hours between both jobs during the summer months to earn some extra money for school. JS tries to get home to see his parents but has been too busy lately due to work. JS has two younger brothers ages 17 and 14 still living at home with his parents. Review of Systems: General: Patient denies fever or chills. Reports occasional fatigue. No recent weight gain or loss of significance. Patient reports HEENT: Reports intermittent diffuse headaches. Denies dizziness. No changes in vision. He does not wear glasses and his last eye exam was 4 years ago. Denies eye drainage, double vision, photophobia, or floaters. Patient reports pressure and tenderness above his eyes when having headaches. No changes in hearing. Has had no recent ear infections, tinnitus or ringing in the ears. Reports occasional pressure in the nose and tightness in the cheekbones and jaw when headaches occur. Denies sinus infections, congestion, and epistaxis. He reports his sense of small is intact. Last dental exam 8 months ago for regular cleaning. Denies bleeding gums, toothache, or dental appliances. Denies dysphagia or throat pain. Denies ulceration of the tongue or mucosa. Neck: No history of trauma, denies recent injury or pain. Patient report occasional neck tenderness and muscle tightness after working long days. Breasts: Denies any breast changes. Denies history of masses or pain. Denies history of rashes. Respiratory: Denies cough, hemoptysis, and sputum production. Patient denies any shortness of breath with resting or with exertion. Patient reports no pain with inspiration or expiration. Patient denies history of pneumonia. Cardiovascular/Peripheral Vascular: No history of murmur or chest palpitations. No edema or claudication. Denies chest pain, peripheral edema, or ……………………………….CONTINUED…………………………