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NU610 Unit 1 Case Study
A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had
them since she was a teenager, but they have become more debilitating recently. The episodes occur
once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the
right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing
sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain
including loud noises and movement. She has taken several over the counter medication like naproxen
and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet
room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals
her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms. Currently
a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the
Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck
stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations,
shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no
vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP
112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and
situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate
conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable
masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No
edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen
with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with
symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air
conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt.
says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve
intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles
reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to
complete heel to shin, gait steady.
