I HUMAN CASE STUDY EMILY GREEN “HEADACHE’’ (Complete And Verified Study material) (5pages) LEARNEXAMS

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 diaphores