Comprehensive iHuman
Case Study: 26-Year-Old
Female Patient with Severe
Frequent Headache, Exams
of Nursing
,Patient Information
• Name: Sarah Johnson
• Age: 26 years
• Gender: Female
• Race/Ethnicity: Caucasian
• Marital Status: Single
• Occupation: Graphic designer, works 40 hours/week, high
screen exposure
• Education: Bachelor’s degree in Fine Arts
• Residence: Lives in an apartment with a roommate in an
urban city
• Insurance: Private insurance through employer
Chief Complaint
“I’ve been having these really bad headaches, about two or three
times a week, for the past few months.”
History of Present Illness (HPI)
Sarah Johnson is a 26-year-old female who presents with a 3-
month history of frequent severe headaches. Pain is described as
unilateral (usually left-sided), throbbing, and moderate to severe
in intensity (7–9/10). Headaches last 6–12 hours, often
beginning in the late morning and worsening by afternoon. They
, are associated with photophobia, phonophobia, and occasional
nausea, but no vomiting.
The headaches are aggravated by screen time, bright lights, and
stress. Resting in a quiet, dark room provides partial relief. OTC
acetaminophen provides minimal benefit. She denies aura,
visual disturbances, speech changes, limb weakness, dizziness,
fever, or neck stiffness.
Frequency: 2–3 episodes per week.
Impact: Missed workdays, decreased productivity, avoidance of
social activities.
Past Medical History
• No chronic illnesses.
• No history of seizures, stroke, or head injury.
Past Surgical History
• Appendectomy at age 15, uncomplicated.
Medications
• Acetaminophen 500 mg as needed (used 2–3 times
weekly).
• No daily prescription medications.
Allergies
• No known drug allergies (NKDA).
Family History
Case Study: 26-Year-Old
Female Patient with Severe
Frequent Headache, Exams
of Nursing
,Patient Information
• Name: Sarah Johnson
• Age: 26 years
• Gender: Female
• Race/Ethnicity: Caucasian
• Marital Status: Single
• Occupation: Graphic designer, works 40 hours/week, high
screen exposure
• Education: Bachelor’s degree in Fine Arts
• Residence: Lives in an apartment with a roommate in an
urban city
• Insurance: Private insurance through employer
Chief Complaint
“I’ve been having these really bad headaches, about two or three
times a week, for the past few months.”
History of Present Illness (HPI)
Sarah Johnson is a 26-year-old female who presents with a 3-
month history of frequent severe headaches. Pain is described as
unilateral (usually left-sided), throbbing, and moderate to severe
in intensity (7–9/10). Headaches last 6–12 hours, often
beginning in the late morning and worsening by afternoon. They
, are associated with photophobia, phonophobia, and occasional
nausea, but no vomiting.
The headaches are aggravated by screen time, bright lights, and
stress. Resting in a quiet, dark room provides partial relief. OTC
acetaminophen provides minimal benefit. She denies aura,
visual disturbances, speech changes, limb weakness, dizziness,
fever, or neck stiffness.
Frequency: 2–3 episodes per week.
Impact: Missed workdays, decreased productivity, avoidance of
social activities.
Past Medical History
• No chronic illnesses.
• No history of seizures, stroke, or head injury.
Past Surgical History
• Appendectomy at age 15, uncomplicated.
Medications
• Acetaminophen 500 mg as needed (used 2–3 times
weekly).
• No daily prescription medications.
Allergies
• No known drug allergies (NKDA).
Family History
