Prescription Assignment – Week 2 – Neuro
Make sure to refresh your memory by reviewing any comments
received on your last week’s assignment and reading your prescription
assignment instructions posted in Week 1. Make sure to use the prescription
template provided in Week 1.
Patient: Mary Margaret Sandefer
Address: 789 Addison Way, Apt 3B, Jacksonville, FL
Age: 32
DOB: January 28th
CC: A headache that started last night.
PMH: Irregular menstrual periods since the age of 12; Tonsillectomy
at age 6; Gravida-0
FMH: Dad – current age 62, had MI at 55 years, currently no health
issues
Mom - current
age 58, migraines (2X monthly), otherwise healthy
Sister -
current age 29, healthy
Social: Drinks a glass of red wine nightly
before bed, denies use of illicit drugs or marijuana, non-smoker; Lives with
her girlfriend of 5 years; Works as a music producer and event promoter.
Meds: multivitamin daily
Allergies: NKDA – allergic to ragweed and pine
trees
Vitals: B/P 122/78, HR 89, Resp 20, SPO2 97% on RA, temp 37.2, LMP: started 4 days ago, Weight 147#, Height 5’7”
HPI: Ms. Sandefer is a 32-year-old female of Hispanic descent who
presents to the clinic with complaint of a headache that started approximately
14 hours ago. When asked, she advised that before the headache started, she
noticed some strange flashes of light, but she was not sure whether they were real.
She states that the headache started mild on the right side of the top of her
head and has gotten progressively worse. She took some ibuprofen and thinks
that it may have helped a little bit, but not very much. She thinks that she
slept a little bit last night but could not sleep normally due to the pain.
However, she did feel better in a dark room than in the light.
ROS:
Cardiac: Denies Palpitation or chest Pain
Respiratory: Denies SOB, wheezing, or other respiratory issues
Gastro: Nauseous since last night – no vomiting
HEENT: Light hurts her eyes and she thinks that loud sounds make the headache worse
Constitutional: Denies fever, weight gain or loss, she states that she would feel fine if the HA would go away
Integumentary: Denies rashes or lesions
Musculoskeletal: Denies muscular or joint pain
Genitourinary: Denies issues with urinating or genital organs. She has gotten used to having irregular periods
Psychiatric: Denies depression, malaise, or other psychiatric issues
Neurological: Headache
Endocrine: Never had problems with sugar or hormones that she knows of
Hematologic / lymphatic: Denies swollen lymph nodes or known blood issues.
Examination: Ms. Sandefer appears to be in pain with eyes squinted, speaking quietly, and frequently touching the right side of her head. She appears otherwise healthy, well formed, and of average size. Her skin is pink, warm, and dry, and normal for ethnicity. Gait is demonstrated as steady. Grips are equal. Cranial nerves are intact to testing. PERRLA is observed. Respirations are equal and unlabored with clear bilateral breath sounds in all lobes. Peripheral pulses are intact/equal at 2+ (radial, carotid, & pedal), S1/S2 auscultated with no extraneous heart sounds. No pedal edema. Abdomen is soft, non-tender, with active bowel sounds in all quadrants.
Your assignment requires you to diagnose Ms. Sandefer; prescribe an appropriate medication for her; and provide all information required by the prescription template. When writing your patient education, make sure to personalize the information with the information you know about this particular person.
NOTE: Make sure you include in your patient teaching, and your diagnosis (including ICD10).
Please closely review your APA references to ensure they are correct. Your APA manual and the Purdue OWL are excellent resources for you to check your work.