Joan is a 35-year-old woman who presents with a complaint of headaches that have been occurring more frequently over the last 2 weeks. She has never had any problems with headaches before. Rarely, she has had a headache after a stressful day but denies premenstrual headaches or frequent headaches until 2 weeks ago. Her headaches are left sided in the temporal area and are severe (7 out of 10 on a scale of 1-10) and throbbing. They occur 3-5 times each week. She occasionally becomes nauseous but rarely vomits. The headaches tend to last several hours and go away if she is able to get sleep. Joan tries to retreat to a dark and quiet corner when the headaches begin. She sometimes sees "spots in front of her eyes" right before the onset of a headache. Otherwise, she has no trouble with her vision, has had no epistaxis, upper respiratory symptoms, or sinus symptoms. She denies trauma to her head or any neck stiffness. She denies fever, chills, numbness, or weakness.

Past Medical History: Besides the headaches, Joan has been well and denies any previous surgeries or hospitalizations other than for 3 uncomplicated vaginal deliveries.

Family History: Migraine headaches in her mother and sister. Her uncle had a benign brain tumor that has been successfully treated.
Social History: The patient does not smoke, drinks 1 beer 3 times each week, and denies ever using recreational drugs. She is married and works as an administrative assistant in a busy office. She has 1 preteen and 2 teenagers at home. Their behaviors sometimes cause her to have some stress. Her husband is supportive and helpful.

Medications: Joan's medications include occasional ibuprofen for "aches and pains." She tried the ibuprofen for the headaches without relief. She takes no other medications. She states that her mother told her that she was allergic to penicillin as a child, but does not know why.

Objective

General: Joan is well groomed. Her manner and speech are appropriate and she is articulate. She is in no apparent distress during this visit.
Vital Signs: The patient is afebrile, B/P 140/90 (which is higher than normal), pulse 86, resp 12.

HEENT: Head atraumatic and normocephalic. PERRLA, sclera clear, conjunctiva without injections. EOM's intact. No AV nicking or papilledema. Optic disks have clear margins. Nasal mucosa is without erythema or drainage. There is no sinus tenderness to palpation. Cranial nerves II-XII are grossly intact

Cardiac: Unremarkable

Neurological: Sensation and proprioception are grossly intact and the Romberg test is negative. Gait is steady. Brudzinski and Kernig signs are negative.

To view the Grading Rubric for this Assignment, please visit the Course Home.

Assignment Requirements

The finished Assignment should be a care plan, encompassing all required items listed. The viewpoint and purpose of this Assignment should be clearly established and sustained.

Before finalizing your work, you should:

Be sure to read the Assignment description carefully

consult the Grading Rubric (under the Course Home) to make sure you have included everything necessary;
utilize spelling and grammar check to minimize errors; and review APA formatting and citation information found in the KU Writing Center, online, or elsewhere in the course.

Your writing assignment should:

Follow the conventions of Standard American English (correct grammar, punctuation, etc.);

be well ordered, logical, and unified, as well as original and insightful;

display superior content, organization, style, and mechanics;

Use APA 6th edition format for organization, style, and crediting sources:

Properly formatted header

12-point, double-spaced, Times New Roman font

use of in-text citations

title page and reference page

use of headings (if applicable)

Submit the Assignment to the unit Dropbox before midnight on the last day of the unit.

Assignment 2: Out-of-Class Activity: Neurological and Skin Examination

During this week you will spend at least 2 hours performing a neurological or skin examination on a family member or friend.

Click here for the SOAP NOTE Template
Click here for the Out-of-Class Activity Document
Assignment Requirements
Before finalizing your work, you should:
be sure to read the Assignment description carefully

consult the Grading Rubric (under the Course Home) to make sure you have included everything necessary;

utilize spelling and grammar check to minimize errors; and

review APA formatting and citation information found in the KU Writing Center, online, or elsewhere in the course.

Your assignment should:

follow the conventions of Standard American English (correct grammar, punctuation, etc.);

be well ordered, logical, and unified, as well as original and insightful;

display superior content, organization, style, and mechanics;