Patient Information

SJS 33, F, African American, Cigna

S.

CC: “pounding headache”

HPI:    Onset: 2 days ago

Location: forehead

Duration: constant

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

Allergies:  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.

HEENT:

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)

O.

Physical exam:

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.

HEENT

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)