NSG 500 Managing Post-Traumatic Headaches in Young Adults: A Case Study 2024; Tina Jones a twenty eight year old Female Soap Note with complete solution-Wilkes

NSG 500 Managing Post-Traumatic Headaches in Young Adults: A Case Study 2024; Tina Jones a twenty eight year old Female Soap Note with complete solution-Wilkes HPI: Tina Jones scheduled appointment to clinic due to head and neck pain that occured twos days after a car accident (fender bender) one week ago. During the time of the incident she was in the passengers seat with seat belt bulked. The fender bender occurred in the parking lot at a relativieluy slow speed of approximately 10-15 MPH per Ms. Jones. Two days after incident she began to have headaches within the back and crown of head as well as neck pain. She did not lose consciousness during the accident or have a scalp injury. Tina further states her headaches are once a day for 1-2 hours and she takes acetaminophen regular strengthen once a day to alleviate pain. By the same token her neck is sore whe she turns her head side to sde. The acetaminophen helps to ease pain to 3/10 on the pain scale. General: She denies fever, chills, fatigue, and weightloss. Head: patient does not have a headache currently and has never had a head trauma in the past. Eyes: Tina states has blurry vision when she reads for long periods of time, but does not wear glasses or contacts. She negates acute visual changes, itching, or tearing. Ears: patient is not experincing ringing of the ears, dizzines, no ear discharge, or ear pain. Nose: Tina is not having epistaxis, rhinorrhea, or sinus pressure. Musculoskeletal: Patient negates difficulties with range of motion, weakness of the muscles, or joint instability. Neurologic: Patient is not experincing tingling, numbness, tremors, loss of sensation, fainting or seizures. Not having bladder or bowel problems. No changes in sleep, coordination, or appetite.