NR 509 Wk 3 – SJS 33, F, African American
SJS 33, F, African American, Cigna
CC: “pounding headache”
HPI: Onset: 2 days ago
Characteristics: dulling pain
Aggravating Factors: loud noise and bright lights
Relieving Factors: rest, closing eyes, Tylenol 500 mg
Treatment: Tylenol 500 mg orally Twice a Day
Current Medications: none
PMHx: Influenza 09//19/16; TDaP 06/5/15. Positive Hepatitis B, Varicella and MMR Titers. Denies any major illnesses or surgery. NR 509 Wk 3 – SJS 33, F, African American.
Soc Hx: Registered Nurse, enjoys shopping, reading and traveling, Married, two children ages 5 & 3, non-smoker, EtoH 2 drinks/week. Patient runs twice a week
Fam Hx: SJS is the oldest child of three. Two brothers no health disorders. Father 61, smoker, Obese, Hypertension, Hyperlipidemia. Mother 59, Hypertension, Hyperlipidemia. Maternal Grandmother 75 (deceased), skin cancer. Maternal Grandfather (deceased) alcoholic, diabetic unknown age of death. Paternal Grandmother 86, no health issues. Paternal Grandfather (deceased) diabetic.
ROS: (Jarvis, 2016)
CONSTITUTIONAL: Denies any weight loss, fever, chills, weakness or fatigue.
Head: Denies head injury, dizziness, syncope, vertigo, or severe headaches. (current headache, occurs monthly around menstrual cycle) NR 509 Wk 3 – SJS 33, F, African American.
Eyes: Denies any difficulty, eye pain, inflammation, lesions, visual loss, blurred vision, double vision or yellow sclera, glaucoma, cataracts, no corrective lenses. (wears glasses)
Ears: Denies hearing loss, earaches, discharge, tinnitus or vertigo
Nose: Denies epistaxis discharge, sinus pain, obstruction or allergy.
Throat: Denies mouth pain, bleeding gums, toothache, lesions in mouth, dysphagia.
CARDIOVASCULAR: Denies cyanosis, chest pain, pressure or discomfort, palpitations or edema, hypertension, anemia. Denies history of murmur, dyspnea with exertion, or coronary artery disease.
PERIPHERAL VASCULAR: Denies pain, numbness, tingling, coldness, discoloration, varicose vein, infection, ulcers or swelling in legs.
RESPIRATORY: Denies shortness of breath, wheezing, or chest pain with breathing. Nonsmoker. Denies history of lung disease.
MUSCULOSKELETAL: Denies history of arthritis, gout, joint pain, stiffness, swelling, muscle pain, weakness or limitation of motion. NR 509 Wk 3 – SJS 33, F, African American.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. Reports no change in bowel or bladder control. (Current headache)
Height 163 cm (5’3), Weight 68.18 kg (150 lbs.). BMI: 26.6
SJS is a 33-year-old mildly overweight African American female not currently under the influence of drugs or alcohol who articulates clearly, ambulates without difficulty and appears to be in no distress.
HEAD: Normocephalic, symmetrical face no weakness or involuntary movements. No tempromaxillary joint tenderness noted upon palpation.
EYES: PERRLA. EOM intact, no ptosis, discharge or crusting. Conjunctivae clear, sclerae white; no lesion or redness. Pupils 3mm brisk reaction (Patient states sensitivity to light upon exam)
EARS: No mass, lesions, discharge or tenderness to palpation. Clear canals. Tympanic membrane boggy clear fluid noted, landmarks intact, no perforation.
NOSE: No deformities or tenderness to palpation, mucosa pink, septum midline.
THROAT: Mucosa and gingivae pink, no lesions. Tongue symmetric and midline. Tonsils not present NR 509 Wk 3 – SJS 33, F, African American.
NECK: Supple with full ROM, no masses, tenderness, lymphadenopathy, no jugular veins distention or carotid bruits.
RESPIRATORY: All lungs fields clear to auscultation. No wheezing. Chest expansion symmetrical. Tactile fremitus equal bilaterally.
CARDIOVASCULAR: no abnormal pulsations, no heaves, Apical impulse at 5th ICS in left MCL, S1-S2 present, no murmur auscultated
EXTREMITIES: Color appropriate for racial background; No redness, cyanosis, edema, varicosities, or calf tenderness. Radial, Posterior tibial, Dorsalis pedis pulses palpable 2+ and equal bilaterally.
MUSCULOSKELETAL: Temporomandibular joint-no slipping or crepitation. Neck- Full range of motion, no pain. Vertebral column- No tenderness, curvature or deformity: full extension, lateral bending and rotation. Arms and legs symmetric bilaterally with full range of motion, no pain or crepitation. Able to maintain flexion against resistance and without tenderness. Upon inspection of muscles throughout body no atrophy noted. Homologous muscles equal bilaterally in size, strength and tone.
NEUROLOGIC: Appearance behavior speech appropriate. Alert and oriented to person, place, time, with coherent thoughts.
Cranial nerve I: Smell distinction intact
Cranial nerve II: Visual acuity 20/20 in right and left eye. No optic disc atrophy
Cranial nerve III, IV, VI: PERRLA. Extraocular movements intact (Patient states sensitivity to light upon exam) NR 509 Wk 3 – SJS 33, F, African American.
Cranial nerve V: Jaw strength equal bilaterally, no asymmetry or pain. Equal sensation to light touch bilaterally.
Cranial nerve VII: Facial movements are symmetrical and intact.
Cranial nerve VIII: Normal tone and whisper test positive.
Cranial nerve XI, X: Uvula and soft palate rise in the midline, gag reflex intact, voice smooth.
Cranial nerve XI: Equal size and strength bilaterally against resistance.
Cranial nerve XII: Tongue is midline, no tremors. Speech is clear and distinct,
Cerebellar function intact as tested by RAM, and Finger-to-finger test, finger to nose and heel to shin test. Negative Romberg sign. Positive point location, extinction, two-point discrimination, graphesthesia, stereognoisis of a key and tactile discrimination. Bicep, Triceps, Brachioradialis and quadriceps reflexes intact at 2+ bilaterally. No clonus noted.
According to Mitsikostas & Rapoport (2015), migraines are characterized by recurrent, severe attacks of headaches and are often accompanied by other symptoms. Migraines affect approximately 12 % of the general population and affects women three time more than men (Mitsikostas & Rapoport, 2015). General prevention includes lifestyle modifications, stress management, healthy diet, exercise, avoiding precipitants, biofeedback and prophylactic medication for frequent severe attacks (Domino& Baldor, 2016). NR 509 Wk 3 – SJS 33, F, African American.
Domino, F. J., & Baldor, R. A. (2016). The 5-minute clinical consult 2017 (25th ed.).
Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Retrieved from
Mitsikostas, D. D., & Rapoport, A. M. (2015). New players in the preventive treatment of
migraine. BMC Medicine, 13279. doi:10.1186/s12916-015-0522-1 NR 509 Wk 3 – SJS 33, F, African American.