Comprehensive Case Study Ihuman Week 9 Of 26-Year-Old With More Frequent Sereve Headaches
Step 1: Patient History
This is a crucial part of the assessment, as the patient’s history can provide key insights into the potential causes of her headaches.
A. Chief Complaint
•
Kathleen Parks is c...
Comprehensive Case Study Ihuman Week
9 Of 26-Year-Old With More Frequent
Sereve Headaches
, Step 1: Patient History
This is a crucial part of the assessment, as the patient’s history can provide key
insights into the potential causes of her headaches.
A. Chief Complaint
• Kathleen Parks is complaining of more frequent and severe headaches.
Gather detailed information:
o When did the headaches begin?
o How often do they occur (frequency)?
o How long do they last (duration)?
o Describe the character of the headaches (throbbing, sharp, etc.).
o Are they associated with nausea, vomiting, visual disturbances, or
photophobia (light sensitivity)?
o Are there any triggers, such as stress, certain foods, or changes in
environment?
B. History of Present Illness (HPI)
• Explore the following aspects:
o Location of the headache (unilateral, bilateral, or generalized).
o Severity of the pain (using a pain scale from 1-10).
o Any history of trauma, recent infections, or recent stressors.
o Family history of migraines or other neurological conditions.
o Medications: Is she taking any pain relief or other medications? Are
these helping?
C. Past Medical History (PMH)
• Investigate if the patient has a history of migraines or other conditions like
hypertension, diabetes, or sinus problems.
D. Social History
• Evaluate her lifestyle, including work stress, caffeine or alcohol intake,
smoking, or illicit drug use.
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