NRNP 6550 Week 10 i-Human Case Study Samantha A
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NRNP6550wk10Ihuman
Name: Samantha A. Higgins 55-year-old
5’6” (168.0cm)
128lb (58 kg)
Chief complaint: Headache Sharp pain of 9/10
Nausea with episode of vomiting Worse in occipital area
Visual disturbance
headache worse with movement loss of balance
History
occasional tension headache
History of Right sided Bell's palsy 5 years ago
high blood pressure (poor control d/t noncompliance) Family history of obesity, diabetes and hypertension
ibuprofen
immunization: 3 years ago
works with home improvement distributor
drinks 2-3 glasses of alcohol everyday and a bottle on weekends cigarette smoker half a pack per day for 17 years
VS:
Bp: 164/104 T: 98.8
P: 136 R:28
O2sat: 98%
Ptosis of right eyelid; right eye deviation “down and out” Right pupil nonreactive
Sharp optic disks
Neck stiffness with flexion. Unable to touch chin to chest
125 words
HPI:
The 55-year-old female patient was brought in by paramedics due to acute onset of severe headache upon waking up. She described the pain as sharp with 9/10 severity predominantly in the occiput area. Associated symptoms reported include visual disturbance, feelings of losing balance, nausea with vomiting episode while in route. Medical history includes hypertension, tension headache, and Bell’s palsy with residual symptoms. She declines to monitor and manage her blood pressure with medication or lifestyle modification. She admits to consuming alcohol daily and is a chronic smoker for 17 years. She is alert and oriented with a BP of 164/104 and PR of 136. Physical exam revealed right eye deviation with ptosis and nonreactive pupil with bilateral sharp optic disks and neck stiffness during flexion……….. Continue
