IHUMAN CASE STUDY. BEBE
BABBITT, 26-YEAR-OLD. REASON
FOR ENCOUNTER: MORE
FREQUENT SEVERE HEADACHES.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Bebe Babbit
• Age: 42 years
• Gender: Female
• Reason for Encounter: More frequent severe headaches
Chief Complaint (CC)
"I've been getting severe headaches more often over the past few weeks."
History of Present Illness (HPI)
Bebe Babbit is a 42-year-old female who presents with progressively worsening
headaches over the past 6 weeks. She reports that the headaches have
become more frequent and more severe than her previous headaches. The
pain is described as throbbing, mainly affecting the right side of her head,
although it occasionally becomes generalized.
The headaches typically last between 4 and 12 hours and occur about 3 to 4
times per week. She rates the pain as 8/10 at its worst. The headaches are
associated with nausea, sensitivity to bright light (photophobia), and sensitivity
to loud sounds (phonophobia). She notes that physical activity tends to worsen
the pain, and she usually has to lie down in a dark, quiet room for relief.
She has tried over-the-counter ibuprofen and acetaminophen with only partial
relief. She denies recent head trauma, fever, neck stiffness, seizures, weakness,
numbness, vision loss, confusion, difficulty speaking, or loss of consciousness.
She reports increased work-related stress and poor sleep over the past month,
which she believes may be contributing to the headaches.
Past Medical History (PMH)
• History of migraine headaches diagnosed several years ago
• Hypertension, controlled with medication
• No history of stroke, seizures, or brain tumours
BABBITT, 26-YEAR-OLD. REASON
FOR ENCOUNTER: MORE
FREQUENT SEVERE HEADACHES.
EXAM STUDY GUIDE. GRADED A+.
LATEST 2026/2027 UPDATE.
,Table of Contents
Section Title
1 History
2 PHYSICAL EXAMINATION (PE) – Objective Findings
3 Assessment
4 TEST RESULTS (Diagnostic Investigations)
5 Diagnosis: Primary Diagnosis & Differential Diagnosis:
6 MANAGEMENT PLAN (PLAN OF CARE)
7 Summary
8 Soap Note
, 1. HISTORY
Patient Identification
• Name: Bebe Babbit
• Age: 42 years
• Gender: Female
• Reason for Encounter: More frequent severe headaches
Chief Complaint (CC)
"I've been getting severe headaches more often over the past few weeks."
History of Present Illness (HPI)
Bebe Babbit is a 42-year-old female who presents with progressively worsening
headaches over the past 6 weeks. She reports that the headaches have
become more frequent and more severe than her previous headaches. The
pain is described as throbbing, mainly affecting the right side of her head,
although it occasionally becomes generalized.
The headaches typically last between 4 and 12 hours and occur about 3 to 4
times per week. She rates the pain as 8/10 at its worst. The headaches are
associated with nausea, sensitivity to bright light (photophobia), and sensitivity
to loud sounds (phonophobia). She notes that physical activity tends to worsen
the pain, and she usually has to lie down in a dark, quiet room for relief.
She has tried over-the-counter ibuprofen and acetaminophen with only partial
relief. She denies recent head trauma, fever, neck stiffness, seizures, weakness,
numbness, vision loss, confusion, difficulty speaking, or loss of consciousness.
She reports increased work-related stress and poor sleep over the past month,
which she believes may be contributing to the headaches.
Past Medical History (PMH)
• History of migraine headaches diagnosed several years ago
• Hypertension, controlled with medication
• No history of stroke, seizures, or brain tumours
