26-Year-Old Female Headache Case Study: SOAP Note & Clinical Reasoning for Nurse Practitioners | Walden University

Week #9 I- v v




HUMAN CASE STUDY FOR A 26 YEARS OLD FEMALE WITH MOR
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E FREQUENT AND SEVERE HEADACHES –
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(CLASS 6512) WALDEN UNIVERSITY LATEST UPDATE WITH CL
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EAR CLINICAL REASONING, DIFFERENTIAL DIAGNOSIS, DIAGN
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OSTICS, MANAGEMENT, AND A SOAP NOTE.v v v v v




i-Human Case Study – Week #9 (2026)
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Class 6512 – Walden University
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Outpatient Clinic Case Study v v v




Patient: 26-Year-Old Female v v




Reason for Encounter: More Frequent, Severe Headaches
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Patient Demographics: v




 Age: 26 years
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 Sex: Female v



 Height: 5’4” (163 cm) v v v



 Weight: 135 lb (61.2 kg) v v v v




Case Mode: Learning mode
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,Case Location: Outpatient clinic with laboratory capabilities
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Attempts Allowed: Multiple v v




2. Chief Complaint (CC) v v




“I’ve been getting headaches more often, and they’re much more severe than before.”
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3. History of Present Illness (HPI) v v v v




The patient is a 26-year-
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old female who reports progressively worsening headaches over the past 3 months
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. She states the headaches now occur 3–
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4 times per week, compared to once monthly previously. The pain is described as thr
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obbing and pulsating, primarily unilateral over the right temporal and frontal re
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gion, occasionally radiating behind the right eye.
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The headaches typically last 6–24 hours and are rated 7–
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9/10 in severity. They are associated with photophobia, phonophobia, and nausea,
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but no vomiting. She reports seeing intermittent shimmering lights in her visual fiel
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d prior to some episodes.
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Headaches are worsened by physical activity, stress, and lack of sleep and partially
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relieved by resting in a dark, quiet room. Over-the-
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counter ibuprofen provides minimal relief. She denies recent head trauma, fever, neck
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stiffness, syncope, or seizures.
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, She reports increased academic stress and irregular sleep patterns. No recent infection
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s or travel.
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Associated Symptoms
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 Photophobia
 Phonophobia
 Nausea
 Visual disturbances (aura-like symptoms)
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 Fatigue




Negative Symptoms
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 No fever or chills
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 No neck stiffness
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 No weakness or numbness
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 No altered mental status
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 No sudden “worst headache of life”
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4. Past Medical History (PMH)
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 Episodic headaches since adolescence (self-diagnosed)
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 No chronic medical conditions
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