Student name: Ashley Rhoby
LAB ASSESSMENT FORM
NEURO
Pt. Initials: MR
Gender: Male
Age: 28
S:
CC: “I have an awful headache”
HPI: Patient is a 28-year-old male c/o of a headache lasting three days.
Patient has tried over the counter Advil 400mg and Tylenol 650mg with
no relief. Patient states headache is worse in the afternoon, especially
since he has been working on the computer for several hours per day
recently. He states the headache begins in the back of his head and
sometimes worsens and spreads to pain coming from “above his ears.”
Patient rates the pain as a 6 out of 10 to start, worsening to 9 out of
10. Patient denies changes in his home and work habits. Patient denies
use of caffeine on a regular basis, states he maybe has one caffeinated
drink per week. Patient denies recent head trauma, difficulty sleeping
or changes in memory or concentration. Patient denies personal history
of neurological disorders, hypertension, recent surgeries, or childhood
seizures.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015. Patient currently does not take
any prescription medications, over the counter drugs, vitamins, or
supplements. Patient has no known allergies.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of
migraines, headaches, brain tumors, epilepsy, Alzheimer’s or
neurological disorders.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active. Patient denies changes
in sleep habits or diet.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Skin, hair, nails: Pt denies any instances of rash, lumps, sores,
itching,
LAB ASSESSMENT FORM
NEURO
Pt. Initials: MR
Gender: Male
Age: 28
S:
CC: “I have an awful headache”
HPI: Patient is a 28-year-old male c/o of a headache lasting three days.
Patient has tried over the counter Advil 400mg and Tylenol 650mg with
no relief. Patient states headache is worse in the afternoon, especially
since he has been working on the computer for several hours per day
recently. He states the headache begins in the back of his head and
sometimes worsens and spreads to pain coming from “above his ears.”
Patient rates the pain as a 6 out of 10 to start, worsening to 9 out of
10. Patient denies changes in his home and work habits. Patient denies
use of caffeine on a regular basis, states he maybe has one caffeinated
drink per week. Patient denies recent head trauma, difficulty sleeping
or changes in memory or concentration. Patient denies personal history
of neurological disorders, hypertension, recent surgeries, or childhood
seizures.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015. Patient currently does not take
any prescription medications, over the counter drugs, vitamins, or
supplements. Patient has no known allergies.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of
migraines, headaches, brain tumors, epilepsy, Alzheimer’s or
neurological disorders.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active. Patient denies changes
in sleep habits or diet.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Skin, hair, nails: Pt denies any instances of rash, lumps, sores,
itching,
