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 p

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.