Week #9 I-HUMAN CASE STUDY FOR A 26 YEARS OLD FEMALE WITH MORE FREQUENT AND SEVERE HEADACHES – (CLASS 6512) WALDEN UNIVERSITY LATEST UPDATE WITH CLEAR CLINICAL REASONING, DIFFERENTIAL DIAGNOSIS, DIAGNOSTICS, MANAGEMENT, AND A SOAP NOTE.

Week #9 I-HUMAN CASE STUDY FOR A 26 YEARS OLD
FEMALE WITH MORE FREQUENT AND SEVERE
HEADACHES – (CLASS 6512) WALDEN UNIVERSITY LATEST
UPDATE WITH CLEAR CLINICAL REASONING,
DIFFERENTIAL DIAGNOSIS, DIAGNOSTICS, MANAGEMENT,
AND A SOAP NOTE.




i-Human Case Study – Week #9 (2026)

Class 6512 – Walden University
Outpatient Clinic Case Study

Patient: 26-Year-Old Female




Reason for Encounter: More Frequent, Severe Headaches

Patient Demographics:

• Age: 26 years
• Sex: Female
• Height: 5’4” (163 cm)
• Weight: 135 lb (61.2 kg)

Case Mode: Learning mode

,Case Location: Outpatient clinic with laboratory capabilities
g; g; g; g; g; g;




Attempts Allowed: Multiple g; g;




2. Chief Complaint (CC) g; g;




“I’ve been getting headaches more often, and they’re much more severe than
g; g; g; g; g; g; g; g; g; g; g;



g; before.”




3. History of Present Illness (HPI) g; g; g; g;




The patient is a 26-year-old female who reports progressively worsening
g; g; g; g; g; g; g; g; g;



g; headaches over the past 3 months. She states the headaches now occur 3–4
g; g; g; g; g; g; g; g; g; g; g; g;



g; times per week, compared to once monthly previously. The pain is described
g; g; g; g; g; g; g; g; g; g; g;



g; as throbbing and pulsating, primarily unilateral over the right temporal
g; g; g; g; g; g; g; g; g;



g; and frontal region, occasionally radiating behind the right eye.
g; g; g; g; g; g; g; g;




The headaches typically last 6–24 hours and are rated 7–9/10 in severity. They
g; g; g; g; g; g; g; g; g; g; g; g;



are associated with photophobia, phonophobia, and nausea, but no vomiting.
g; g; g; g; g; g; g; g; g; g;



g; She reports seeing intermittent shimmering lights in her visual field prior to
g; g; g; g; g; g; g; g; g; g; g;



g; some episodes. g;




Headaches are worsened by physical activity, stress, and lack of sleep and
g; g; g; g; g; g; g; g; g; g; g;



g; partially relieved by resting in a dark, quiet room. Over-the-counter ibuprofen
g; g; g; g; g; g; g; g; g; g;



g; provides minimal relief. She denies recent head trauma, fever, neck stiffness,
g; g; g; g; g; g; g; g; g; g;



g; syncope, or seizures. g; g;

, She reports increased academic stress and irregular sleep patterns. No recent
g; g; g; g; g; g; g; g; g; g;



g; infections or travel.
g; g;




Associated Symptoms g;




• Photophobia
• Phonophobia
• Nausea
• Visual disturbances (aura-like symptoms)
g; g; g;



• Fatigue




Negative Symptoms g;




• No fever or chills
g; g; g;



• No neck stiffness
g; g;



• No weakness or numbness
g; g; g;



• No altered mental status
g; g; g;



• No sudden “worst headache of life”
g; g; g; g; g;




4. Past Medical History (PMH)
g; g; g;




• Episodic headaches since adolescence (self-diagnosed)
g; g; g; g;



• No chronic medical conditions
g; g; g;