Patient is 29 year old self referred nurse who presents with complaint of increase in frequency of migraine headaches. Patient reports migraines are frontal, throbbing, rates 7-8/10 on pain scale, usually early am or at hour of sleep, last 1-2 hours, and have been increasing in intensity (6/10 to 8/10) and frequency (from twice a month to 1-2 a week). She states Frovatriptan 2.5mg and rest has usually brought relief, and now is requiring 2nd dose of Frovatriptan to obtain relief. She states her migraines are associated c nausea and sensitivity to light. Pt states she normally experiences migraines around her menstrual cycle and when she consumes ‘too much’ alcohol. Over the past two months, her shift at the hospital has included rotating day/night 12 hour shifts. She admits to increased stress levels at work secondary to increased patient load and acuity.
Medications: B complex vitamin 50mg PO BID; Frovatriptan 2.5mg PO q2h PRN migraine (max 3 tabs/24hours)
Allergies: NKDA
Tobacco – pt states she smoked 1 ppd x 12 years, quit 4 months ago c assistance of Chantix
Alcohol – 2 drinks on weekend.
Drug – denies
Childhood Illnesses – Pt states chicken pox when 6 years old
Adult illnesses – Migraine headaches first appeared at age 13 with onset of menarche – diagnosed as migraine headaches at age 14.
Surgical history – Wisdom teeth x 4 (age 17) removed s complications
OB/GYN – Pt states no pregnancies, menarche at age 13, condoms for birth control, is sexually active and currently involved in heterosexual relationship for past 6 months.
Psych – Denies any psychiatric issues
Health Maintenance
Immunizations – childhood immunizations Hepatitis A/B/C, rotavirus, DTaP, Polio, MMR, Varicella and Meningococcal up to date, received booster Hepatitis C vaccination and yearly Influenza vaccinations thru work as a nurse.
Screenings – As a nurse, pt receives yearly TB testing (negative). She states yearly pap smears c gyn (negative), has yet to have a mammogram, stool for OB, or cholesterol testing.
Family History – Pt states she is adopted. Her adoptive parents were not provided family history.

Personal and Social History – Pt is 29 year old nurse who relocated to Baltimore from Florida after receiving her Bachelors in Science from University of Florida. She currently works on the Neuroscience Unit of Johns Hopkins Hospital. She lives alone and is involved in a heterosexual relationship for past 6 months. She states increased stress at work secondary to rotating and extra shifts. Pt states a good social/support network consisting mostly of coworkers and her boyfriend. She lists leisure activities of cooking/baking and exercises as stress relievers. Patient states she is spiritual and lists religious affiliation as Protestant. She is independent with activities of daily living.
Lifestyle habits – pt reports has been running/exercising daily for past 6 months, maintains a diet of lean meats c plenty of fruits and vegetables and keeps fried/fatty food to once/twice a month.
Safety Measures – Pt states she wears seatbelt, and utilizes sunblock.
Alternative Health – Pt states she receives monthly massages for stress reduction and muscle tightness.
REVIEW OF SYSTEMS
General – Pt states intentional 10 pound weight loss over past 6 months which she relates to daily exercise and a healthier diet.
Skin – Denies any changes in skin, hair, or nails. Denies any moles
HEENT – States increase in frequency and duration of migraine headaches denies vision changes, last eye exam 2 years ago, does not utilize corrective eyewear. She denies any changes in hearing, tinnitus, and vertigo. She denies nasal congestion, tenderness or discharge. She admits to very sore throat after return from Mardi gras on 3/8. Last dental exam 1 year ago.
Neck – Denies any pain/tenderness or ROM difficulties.
Breasts – No pain/tenderness/lumps. Performs monthly self exams.
Respiratory - Non-productive cough for 4 days after return from Mari Gras on 3/8 – has since resolved. Otherwise, denies dyspnea, wheezing, pneumonia. Never had a chest x-ray
Cardiovascular – No heart trouble, disease, hypertension, heart murmurs, chest pain or discomfort, no palpitations, dyspnea, orthopnea, or edema. Never has had EKG.
Gastrointestinal – Denies any dental trouble or difficulty swallowing. Admits to +sore throat earlier in month which has resolved, no heartburn or appetite changes. Nausea only during her migraine headaches. Bowel movements every 1-2 days – brown, soft and formed. Denies any abdominal pain or excessive gas. Denies any history of gallbladder or liver problems.
Urinary – Denies burning/urgency or difficulty urinating, denies polyuria and nocturia.
Genital – Menarche at age 13, periods lasting 4-5 days with associated migraines. Denies history of STDs, vaginal discharge, puritis, sores, and lumps. No previous pregnancies. Pt states condom as method of birth control as birth control pills trigger hormonal migraines. Pt denies any sexual dysfunction and participates in sexual relations with her boyfriend of 6 months. Pt denies unprotected sexual encounters.
Peripheral Vascular – Positive leg cramps while running, denies history of DVT, LE edema or color changes in fingertips or toes during cold weather.
Musculoskeletal – Pt states leg cramps. Pt states calf and thigh pain that occur during running, relieved by rest, hot baths, and her monthly massages. Denies any further joint pain or muscular difficulties.
Psychiatric - No nervousness, mood swings. Names work as biggest stressor with baking and exercise as major stress reliever. Also states close circle of friends and boyfriend as support system.
Neurologic - Increase in migraine pain and frequency. Denies changes in orientation, memory, insight, or judgment. Denies dizziness, vertigo, syncope, weakness, numbness or change in sensation, tremors or involuntary movements/ticks.
Hematologic – Denies easy bruising or history of transfusions, UGIB or LGIB, or blood disorders.
Endocrine – Denies Thyroid diagnosis, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size
COMPREHENSIVE EXHAMINATION:
General Survey: pt is pleasant, 29 year old, well groomed 5’4” 135lbs female. BMI = 23. Respiratory rate even, unlabored, and 12 per minute. (Blood Pressure/Temperature deferred 2/2 lack of thermometer and blood pressure machine/cuff)
Skin/Hair: skin is warm and dry, tattoos noted on upper back and both hips. Hair is shiny and fixed neatly. Nails trimmed s clubbing or cyanosis.
HEENT: Head: Size of head/neck proportionate, facial expression relaxed, no movement/tics noted. Head midline, neck/throat midline. Pt demonstrates ROM of neck, no glandular tenderness of lymph nodes or goiter appreciated on exam. Bilateral carotid arteries palpable s bruit.
Eyes: Pupils 3-4MM and equal, eyelids equal s dropping, eyebrows/lashes present, conjunctiva non-inflamed and pink, sclera white, lacrimal apparatus not appreciated, pupils and irises equal, accommodation and convergence intact, gross visual fields intact by confrontation, Extraocular muscle movements and position test intact s nystagmus noted.
(Visual acuity/Papillary light reflex/corneal light reflex not performed 2/2 lack of Snellen card and Ophthalmoscope.)
Ear: Bilaterally equal, no redness/drainage noted. No redness or tenderness noted. Positive Whisper, Negative Romberg.
(Tympanic membrane and canal exam not performed 2/2 lack of Otoscope. Weber and Rinne not performed 2/2 lack of vibrating/tuning fork.)
Mouth/Throat: Lips/mouth s sores/cracks/cankers. Good Dentition. Equal elevation of soft palate, tonsils noted and non-swollen/no exudates. Good voice quality s hoarseness or wheeze.
Nose: Midline s deformities. Denies drainage. No tenderness to palpation. + Smell/airflow each nare.
(Septum/turbinate/Mucosa not examined 2/2 lack of otoscope)
Sinus: No tenderness of frontal or maxillary sinus.
(Transillumination not performed 2/2 lack of otoscope.)
Cardiac/ Peripheral Vascular: JVP 3cm above sternal angle c HOB 30 degrees. Carotid upstrokes brisk, no bruits. No heaves, lifts, or thrills. 5th intercostals space c PMI is tapping. S1 and S2 appreciated s murmurs. No abdominal or femoral bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are bilaterally equal and 2+. Negative Allen test bilaterally. No lower extremity edema, redness, varicosities, or ulcerations noted. Extremities are warm and pink bilaterally.
Respiratory: Respirations equal and non-labored s accessory muscle use. Thorax symmetric c equal/adequate expansion. Lungs resonant and bronchovesicular breath sounds s rales, rhonchi, or wheezes. Diaphragm descends 4cm bilaterally.
Abdomen: Flat c active bowel sounds. Soft/non-tender, no masses or hepatosplenomegally. Liver span is 7cm MCL, edge non-palpable. Spleen/kidneys non-palpable. Negative CVA tenderness.
Neurological: Alert and oriented x 3, cooperative and thought coherent. Cranial nerves intact. Good muscle tone, ROM, and 5/5 strength in all extremities. Positive RAMs and negative Romberg. Stable gait. Light touch, position sense, stereogenesis, point location, two point discrimination, and graphesthesia intact. Negative extinction. Reflexes 2+ and symmetric. Biceps Triceps Brach Knee Ankle Plant
Rt 2+ 2+ 2+ 2+ 2+ Down
Lt 2+ 2+ 2+ 2+ 2+ Down

(Temperature testing not warranted, Vibration test not performed 2/2 lack of vibrating/tuning fork.)
Musculoskeletal : Good ROM of all joints. No TMJ tenderness or inequality. Pt states slight soreness of bilateral calf, quads and hamstrings.
Nutrition/BMI: pt reports has been running/exercising daily for past 6 months, maintains a diet of lean meats c plenty of fruits and vegetables and keeps fried/fatty food to once a month. 5’4” and weight of 135 pounds. BMI is 23.
NURSING DIAGNOSIS
1. Migraine headaches - 29 year old woman with migraine headaches since menarche, with throbbing migraines that have been both increasing in intensity and frequency. Migraines are associated c menses and sleep cycle disturbances and relieved by medication and rest. Neuro exam negative for motor or sensory deficits.
Plan
• Discuss features of migraine headaches and triggers (hormonal, stress, sleep cycle changes, dehydration)
• Discuss stress management and potential for decreasing shift changes (all day or all night shifts)
• Continue Frovatriptan PRN as it does relieve migraines and is within max dosage recommendations.

2. Musculoskeletal tenderness of thighs/calves – pt states irritation/tenderness began with addition of running to daily workouts. No history of trauma or signs of PVD. Pain does not radiate and does not have motor or sensory deficits.
Plan
• Discuss importance of warm up and cool down pre/post workouts/running
• Discuss lower impact aerobic activities such as biking/elliptical that could be interspaced c running during week