Nursing Homework week 7

· Age: 45 years

· Biological Sex: Female

· Race: Hispanic

· Insurance: PPO

· Referral: No referral

⚕️ Clinical Information

· Time with Patient: 35 minutes

· Consult with Preceptor: 10 minutes

· Type of Decision-Making: Moderate complexity

· Reason for Visit: New consult

· Chief Complaint: “Severe headache for the last 2 days with light sensitivity and nausea.”

· Type of H&P: Problem-focused

🧠 History & Findings

Subjective: Patient reports a throbbing headache over the right temple for two days, rated 8/10, associated with photophobia, nausea, and mild vomiting. Denies fever, neck stiffness, visual loss, or weakness. History of recurrent migraines, usually triggered by stress or lack of sleep. No recent trauma.

Objective:

· Vitals: BP 128/82, HR 84, RR 18, Temp 98.3°F

· Neuro exam: Alert, oriented ×3, cranial nerves II–XII intact, normal strength and reflexes, no focal deficits.

· No meningeal signs or visual disturbances.

Assessment: Acute migraine without aura (G43.009)

🧾 ICD-10 Diagnosis Codes

1. G43.009 – Migraine without aura, not intractable

2. R11.0 – Nausea

3. R51.9 – Headache, unspecified

💊 CPT® Billing Codes

1. 99203 – Office or other outpatient visit for a new patient, moderate complexity

2. J1885 – Injection, ketorolac tromethamine, per 15 mg (if given)

3. 96372 – Therapeutic injection, subcutaneous or intramuscular

💉 Medications

· OTC Drugs Taken Regularly: Ibuprofen PRN

· Rx Currently Prescribed:

· Sumatriptan 50 mg PO PRN migraine (may repeat once after 2 hours)

· Ketorolac 30 mg IM once in clinic

· New/Refilled Rx This Visit: Yes – Sumatriptan

🧩 Social Problems Addressed

· Stress management

· Nutrition/Exercise (sleep hygiene and hydration counseling)

🗒️ Clinical Notes

Patient is a 45-year-old Hispanic female presenting with acute migraine crisis. Symptoms consistent with previous migraine episodes. No red flag signs. Administered ketorolac 30 mg IM with partial relief after 30 minutes. Advised to rest in dark room, maintain hydration, avoid known triggers, and follow-up if symptoms persist or worsen. Prescribed sumatriptan 50 mg for acute management. Educated on stress management, sleep hygiene, and avoidance of caffeine excess. Patient verbalized understanding.

🧠 Procedure/Skills (Observed/Assisted/Performed)

· Physical Assessment

· General Skills

· Neurology Assessment Skills