Informant: A Reliable Patient and CMC Chart - Paper Example

Chief Complaint: The 39-year-old accountant complained of worsening incidences of headaches in the past month. Initially, the woman noticed that she would experience headaches late in the day after working on her computer for several hours. However, over time she noticed that she is experiencing difficulties in working on her computer screen and would later experience headaches in the course of the day. The woman noticed that distancing herself from the machine helps her reduce the effect of the computer on her eyes. However, she also noticed that the blurry figures on the computer make it impossible for her to expedite her duties as is recommended.

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The woman mentions that she feels intense pressure across her forehead. She says that using Tylenol helps her resolve the headache. Her typical headache can be described on a scale of 4-5/10 and lasts for at least an hour. The headache incidences last 3-4 days in a week. The woman connotes that the main reason for her visit was motivated by the fact that the headache became severe after work. In fact, the pan went up to a scale of about 7/10 and lasted for several hours. Increased incidences of headaches are known to lead to an aneurysm (Pugh & Youngblood, 2002). She also felt nauseated although she was unable to vomit. The woman described that her only reprieve as going to bed. Her condition now is that she is experiencing a mild headache.

Habits:

The woman is a non-smoker

She occasionally takes a glass of wine

She does not rely on recreational drugs

Vital signs

BP 110/80

Temperature 99.10 F

Heart Rate 72 bpm

PhxMedication- OCP (for menorrhagia)

Allergies- the woman has Keflex, which causes rashes

Menorrhagia- She did a pelvic ultrasound, which illuminated that she had uterine fibroid in 2015

Patient Medical History

The case is the first incidence of admission for the 39-year-old. She occasionally experiences headaches and fatigue, but a little rest and painkillers help her ease the pain. She describes her associated symptoms as accompanied by pain, dizziness, and palpitations. The impacts of nausea further complicate her situation. She has not experienced blood transfusion and has not been on any hormone replacement therapies. She is unaware of her cholesterol levels and rarely adheres to diets.

Social History

The woman is under work stress. She was given a promotion last year and thus, her work schedule changed. Moreover, her company was downsizing, which implies that several of her colleagues were laid off. To this effect, she has been forced to work for longer hours and also covers the gaps existing in her organization. The lady is a single woman and does not engage in sexual activities. She spends a significant amount of her time in the local theater doing community productions. Involvement in several activities without rest may be a primary cause of headaches (Hogan-Quigley, Palm & Bickley, 2012). Her mother has a medical history of hypertension and diabetes. The patient is mostly concerned with her health status, as her aunt died of a ruptured brain aneurysm.

Patient Description

Age Range: 35-45

Gender: Female

Race: White

Educational level: 4 years Bachelor degree

Socio-economic level: Middle class

Appearance- Well-dressed but anxious

Attitude: Positively wants to identify the reason for the consistent headaches. Previous histories of her aunt's headache situation that led to a brain aneurysm is her primary concern, though does not openly accept

Props Required for Evaluation

A visual acuity card will help test the impacts of the headache and the possible cause (Bickley & Szilagyi, 2012)

References

Bickley, L., & Szilagyi, P. G. (2012). Bates' guide to physical examination and history-taking. Lippincott Williams & Wilkins.

Hogan-Quigley, B., Palm, M. L., & Bickley, L. S. (2012). Bates' nursing guide to physical examination and history taking. Wolters Kluwer Health/Lippincott Williams & Wilkins.

Pugh, C. M., & Youngblood, P. (2002). Development and validation of assessment measures for a newly developed physical examination simulator. Journal of the American Medical Informatics Association, 9(5), 448-460.