NR509 Non-Specific Headache Assessment

NR509 Non-Specific Headache Assessment

NR509 Non-Specific Headache Assessment

*This form (Complete one available on Request) should be used by students to practice as they rotate through the corresponding immersion stations. While the subjective assessment portion of this case is not included in the final immersion evaluation, students should be able to collect and assimilate pertinent patient history data as they prepare to start their practicum courses.

Most of the physical examination techniques will be included in the final head to toe immersion evaluation. Those parts that are not included are highlighted in bold letters. The exact immersion exam steps, that will need to be completed for immersion evaluation purposes, are contained in the NR 509 Immersion Physical Examination Study Guide.

Non-specific Headache
Patient Information
Jacob, a 50 year-old male, presents with chief concern of headache. He reports episodes lasting minutes to days. He reports the headache is “bandlike” and feels like “someone is squeezing my head.” The pain is described as dull and
constant and is accompanied by tensing of the neck muscles. The pain is bilateral, pressing or tightening in quality and of mild to moderate intensity. The pain does not worsen with physical activity. There is no nausea, but photophobia at times. He has tried OTC ibuprophen with minimal relief.

INTRODUCTION
_____1. Introduces self as NP student
_____2. Acknowledges purpose of exam
_____3. Asks questions in an appropriate, professional, manner
CC / HPI
_____1. Includes the following:
? Onset
? Location
? Duration/Timing
? Characteristics/Quality/Severity
? Aggravating factors/Associated Symptoms
? Relieving factors
? Treatment/Medications/Remedies
PMH
_____1. Major childhood illnesses _____5. Immunizations
_____2. Major adult illnesses _____6. Allergies to medications, foods and environment
_____3. Surgeries _____7. Medications (including RX, OTC, herbal)
_____4. Hospitalizations
FAMILY HISTORY
_____1. Asks about both parents
_____2. Siblings
SOCIAL HISTORY
_____1. Occupation
_____2. Relationship status
_____3. Children
HABITS
_____1. Tobacco
_____2. ETOH/Illegal Drug Use
ROS
_____1. Constitutional _____4. Cardiovascular/Lungs
_____2. HEENT _____5. Neurologic
_____3. Neck/Lymphatic
Sub-total History Items Correct: ______/23

EPISODIC PHYSICAL EXAMINATION
(Items in bold are not included in the final immersion evaluation)

Kindly navigate to ORDER NOW for a complete and more resourceful answer.