Case LAB ASSESSMENT FORM NEURO Pt. Initials: MR Gender: Male Age: 28 S: CC: “I have an awful headache” HPI: Patient is a 28-year-old male c/o of a headache lasting three days. Patient has tried over the counter Advil 400mg and Tylenol 650mg with no relief

Case LAB ASSESSMENT FORM NEURO Pt. Initials: MR Gender: Male Age: 28 S: CC: “I have an awful headache” HPI: Patient is a 28-year-old male c/o of a headache lasting three days. Patient has tried over the counter Advil 400mg and Tylenol 650mg with no relief. P LAB ASSESSMENT FORM NEURO Pt. Initials: MR Gender: Male Age: 28 S: CC: “I have an awful headache” HPI: Patient is a 28-year-old male c/o of a headache lasting three days. Patient has tried over the counter Advil 400mg and Tylenol 650mg with no relief. Patient states headache is worse in the afternoon, especially since he has been working on the computer for several hours per day recently. He states the headache begins in the back of his head and sometimes worsens and spreads to pain coming from “above his ears.” Patient rates the pain as a 6 out of 10 to start, worsening to 9 out of 10. Patient denies changes in his home and work habits. Patient denies use of caffeine on a regular basis, states he maybe has one caffeinated drink per week. Patient denies recent head trauma, difficulty sleeping or changes in memory or concentration. Patient denies personal history of neurological disorders, hypertension, recent surgeries, or childhood seizures. PMH: Patient has a past medical history of chicken pox, and tonsillitis and underwent a tonsillectomy in 2015. Patient currently does not take any prescription medications, over the counter drugs, vitamins, or supplements. Patient has no known allergies. FH: Patient’s father has a history of heart disease, high blood pressure, and high cholesterol. Patient’s mother has a history of hypothyroidism and gestational diabetes. Patient denies any family history of migraines, headaches, brain tumors, epilepsy, Alzheimer’s or neurological disorders. SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per week. Patient participates in a regular exercise regimen 3-4 days per week. Patient is married and is sexually active. Patient denies changes in sleep habits or diet. ROS: General: Pt denies any recent weight changes, weakness, fatigue or fevers. Skin, hair, nails: Pt denies any instances of rash, lumps, sores, itching,