NURS 634 SOAP NOTE 5 Comprehensive History and Physical Examination

History & Physical Examination Patient Demographics: Name: T.T Age/race/sex: 33/Caucasian/male Clinical site: Primary Care clinic-HCM SUBJECTIVE DATA Chief Complaints “I’m here for my annual wellness exam and establishment of PCP” History of Present Illness: T.T is a 33 year old Caucasian male who presents to the primary care clinic today for a wellness exam and with a 10 year history of headache pain. He reports the headaches occur about every 3 years and last daily for about one month. He reports anywhere from 5-8 headaches/day. They usually come on suddenly without any warning or aura that he’s aware of, and he describes them as debilitating. He has to lie down when the attack comes on due to its severity. The pain is unilateral in the temporal region and felt behind the eye on the side of pain. The headaches are coupled with tearing of the same eye and congestion of the nose on the side of pain. Although, he's pain free at presentation today, his last headache was this morning, the pain was described as sharp and shooting; rated 10/10; aggravated by movement, light, and sound; relieved with rest and Sumatriptan, which he has been taking since 2011. The pain can last up to about one hour without treatment and is relived within 10-15 minutes with taking Sumatriptan. He first experienced these headaches in 2007, while living in Germany and attributed them to the air quality, so did not seek any medical care at that time, only took OTC Tylenol or Motrin with some relief. From about 2007 to 2010 the pain disappeared during which time he had moved back to the states. The pain then returned with the same severity, intensity, quality, and character around 2011. These factors together along with a family history of migraines in his mother lead him to see a healthcare provider, whom as he recalls diagnosed him as having headaches, unknown as to which type, and placed him on the Sumatriptan. Today he’s hoping to find something that can help lessen the headache attacks but he doesn’t want to be taken off of his current medication because he feels it works really well when an attack comes on. Past Medical History: ● Headaches-unknown type- dx in 2011 at age 27 Past Surgical History: ● No surgeries to date Allergies: No reported food, environmental, or medication allergies. Medications: Sumatriptan 100 mg 1 tablet by mouth daily started in 2011 for headaches of unknown type.