Walden University School of Nursing
I-Human Case Analysis: Week 9 Clinical Experience
Comprehensive Outpatient Assessment of a 26-Year-Old Female With
Progressive, Frequent, and Severe Headache Symptoms
,Patient Demographics
• Age: 26 years
• Sex: Female
• Ethnicity: Not specified
• Source of History: Patient (reliable)
• Height 5’6 (168cm)
Chief Complaint
“I’ve been having severe headaches several times a week.”
History of Present Illness (HPI)
The patient is a 26-year-old female who presents with recurrent severe
headaches that began approximately 8 months ago and have
progressively increased in frequency. She currently experiences
headaches 3–4 times per week, lasting 6–24 hours per episode.
The pain is described as throbbing, moderate to severe (8/10), and
typically unilateral, most often localized to the right temporal region,
though it occasionally becomes bilateral. Headaches are worsened by
physical activity, bright lights, and loud noises, and are associated with
, nausea and intermittent vomiting. She reports relief only when lying
down in a dark, quiet room.
She denies aura, vision loss, weakness, numbness, confusion, fever,
neck stiffness, head trauma, or loss of consciousness. She denies this
being the “worst headache of her life.” Over-the-counter ibuprofen
provides minimal relief. Triggers appear to include sleep deprivation,
stress, and skipped meals.
Past Medical History
• No chronic medical conditions reported
Surgical History
• No prior surgeries
Medications
• Ibuprofen 400–600 mg as needed for headache (2–3 times
weekly)
Allergies
• No known drug allergies (NKDA)
I-Human Case Analysis: Week 9 Clinical Experience
Comprehensive Outpatient Assessment of a 26-Year-Old Female With
Progressive, Frequent, and Severe Headache Symptoms
,Patient Demographics
• Age: 26 years
• Sex: Female
• Ethnicity: Not specified
• Source of History: Patient (reliable)
• Height 5’6 (168cm)
Chief Complaint
“I’ve been having severe headaches several times a week.”
History of Present Illness (HPI)
The patient is a 26-year-old female who presents with recurrent severe
headaches that began approximately 8 months ago and have
progressively increased in frequency. She currently experiences
headaches 3–4 times per week, lasting 6–24 hours per episode.
The pain is described as throbbing, moderate to severe (8/10), and
typically unilateral, most often localized to the right temporal region,
though it occasionally becomes bilateral. Headaches are worsened by
physical activity, bright lights, and loud noises, and are associated with
, nausea and intermittent vomiting. She reports relief only when lying
down in a dark, quiet room.
She denies aura, vision loss, weakness, numbness, confusion, fever,
neck stiffness, head trauma, or loss of consciousness. She denies this
being the “worst headache of her life.” Over-the-counter ibuprofen
provides minimal relief. Triggers appear to include sleep deprivation,
stress, and skipped meals.
Past Medical History
• No chronic medical conditions reported
Surgical History
• No prior surgeries
Medications
• Ibuprofen 400–600 mg as needed for headache (2–3 times
weekly)
Allergies
• No known drug allergies (NKDA)
