I HUMAN CASE STUDY EMILY GREEN
“HEADACHE’’
I. Subjective Data
A. Chief Complaint (CC): “Headache”
B. History of Present Illness (HPI): Mrs. Green is a 22 years old full-time student at a
community college who presented to the clinic with cc of a headache. She reports her
headache started yesterday morning, lasting about 30 hours. It is a worsening, more
frequent, pulsating/throbbing, and rated an 8/10. The headache started at the left temple
and radiates to her whole head. Associated symptoms include nausea that occurs with
worsening headache. Aggravating factors include loud noise, light, red wine, and
caffeine. Alleviating factors laying down in a quite dark room. Pt. has been taking
Tylenol every 4 hours with little relief. Pt report recent increase in stress and decrease
sleep. She denies SOB, chest pain, dizziness, seizure, memory issues, head trauma,
visuals changes, neck stiff, and falls
C. Last Menstrual Period: (LMP- if applicable): forgot to ask
D. Allergies: NKA
E. Past Medical History: Non contributory
F. Family History:
Father: HTN.
Mother: Headache
Siblings: Brother: healthy. Sister: Headache
Children siblings: No children
G. Surgery History: Non contributary
H. Social History: Pt. is a full-time student. She is single and recently broke up with her
boyfriend. She lives with one of her girlfriends. She denies smoking and illicit drug use. Pt.
drinks on weekends with her friends.
I. Sexual Activity: No.
J. Health Maintenance:
Up to date on his immunization, including flu.
L. Current medications:
Birth control
Tylenol every 4 hrs. PRN for pain.
M. Review of Systems (ROS):
• Constitutional (General overall health state): Denies fevers, chills, fatigue, night
sweats, or weight loss or gain. Reports headache, nausea, disrupted eating habits,
decreased sleep, and increased stress.
• Skin & Hair: Denies diaphoresis, dryness, pruritis, changes in hair or nails, rashes,
new or changing lesions.
• Head: Reports headache. Denies head injury.
• Eyes: Denies vision changes, pain, diplopia, scotomata, lacrimation, inflammation,
infection. Reports photophobia.
• Ears: Denies hearing problems otalgia, tinnitus, vertigo, otorrhea, popping/cracking.
• Nose/Sinuses: Reports no change in sense of smell, denies discharge, epistaxis,
, obstruction, sinus pain, anosmia.
“HEADACHE’’
I. Subjective Data
A. Chief Complaint (CC): “Headache”
B. History of Present Illness (HPI): Mrs. Green is a 22 years old full-time student at a
community college who presented to the clinic with cc of a headache. She reports her
headache started yesterday morning, lasting about 30 hours. It is a worsening, more
frequent, pulsating/throbbing, and rated an 8/10. The headache started at the left temple
and radiates to her whole head. Associated symptoms include nausea that occurs with
worsening headache. Aggravating factors include loud noise, light, red wine, and
caffeine. Alleviating factors laying down in a quite dark room. Pt. has been taking
Tylenol every 4 hours with little relief. Pt report recent increase in stress and decrease
sleep. She denies SOB, chest pain, dizziness, seizure, memory issues, head trauma,
visuals changes, neck stiff, and falls
C. Last Menstrual Period: (LMP- if applicable): forgot to ask
D. Allergies: NKA
E. Past Medical History: Non contributory
F. Family History:
Father: HTN.
Mother: Headache
Siblings: Brother: healthy. Sister: Headache
Children siblings: No children
G. Surgery History: Non contributary
H. Social History: Pt. is a full-time student. She is single and recently broke up with her
boyfriend. She lives with one of her girlfriends. She denies smoking and illicit drug use. Pt.
drinks on weekends with her friends.
I. Sexual Activity: No.
J. Health Maintenance:
Up to date on his immunization, including flu.
L. Current medications:
Birth control
Tylenol every 4 hrs. PRN for pain.
M. Review of Systems (ROS):
• Constitutional (General overall health state): Denies fevers, chills, fatigue, night
sweats, or weight loss or gain. Reports headache, nausea, disrupted eating habits,
decreased sleep, and increased stress.
• Skin & Hair: Denies diaphoresis, dryness, pruritis, changes in hair or nails, rashes,
new or changing lesions.
• Head: Reports headache. Denies head injury.
• Eyes: Denies vision changes, pain, diplopia, scotomata, lacrimation, inflammation,
infection. Reports photophobia.
• Ears: Denies hearing problems otalgia, tinnitus, vertigo, otorrhea, popping/cracking.
• Nose/Sinuses: Reports no change in sense of smell, denies discharge, epistaxis,
, obstruction, sinus pain, anosmia.
