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Case Study 1: Headache
Douglas Boag
Walden University
NURS 6521Advanced Pharmacology
October 24, 2019
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Case Study 1: Headache
Case Study 1: Headaches; A 20-year-old male complains of experiencing intermittent
headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs
above the eyes and spreads through the nose, cheekbones, and jaw.
Patient Initials: DB Age: 20 Gender: Male
Subjective Data
Chief Complaint (CC): Headache
History of Present Illness (HPI):
A 20-year-old male complains of experiencing intermittent headaches. The headaches
diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and
spreads through the nose, cheekbones, and jaw.
Medications: Tylenol 650mg PO Q6H PRN headache
Allergies: No known drug, food, or environmental allergies.
Past Medical History (PMH): None
Past Surgical History (PSH): Tonsillectomy
Personal/Social History: The patient is working in construction and going to school part-
time. The patient is unmarried with zero children. The patient denies smoking and illicit drug
use. The patient does not drink alcohol. The patient is very active, goes to the gym at least five
times a week. He does drink caffeine (soda, coffee, and energy drinks) but has been cutting back
recently.
Immunization History: Immunizations are up to date. Gets the flu vaccine routinely every
year.
Case Study 1: Headache
Douglas Boag
Walden University
NURS 6521Advanced Pharmacology
October 24, 2019
, 2
Case Study 1: Headache
Case Study 1: Headaches; A 20-year-old male complains of experiencing intermittent
headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs
above the eyes and spreads through the nose, cheekbones, and jaw.
Patient Initials: DB Age: 20 Gender: Male
Subjective Data
Chief Complaint (CC): Headache
History of Present Illness (HPI):
A 20-year-old male complains of experiencing intermittent headaches. The headaches
diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and
spreads through the nose, cheekbones, and jaw.
Medications: Tylenol 650mg PO Q6H PRN headache
Allergies: No known drug, food, or environmental allergies.
Past Medical History (PMH): None
Past Surgical History (PSH): Tonsillectomy
Personal/Social History: The patient is working in construction and going to school part-
time. The patient is unmarried with zero children. The patient denies smoking and illicit drug
use. The patient does not drink alcohol. The patient is very active, goes to the gym at least five
times a week. He does drink caffeine (soda, coffee, and energy drinks) but has been cutting back
recently.
Immunization History: Immunizations are up to date. Gets the flu vaccine routinely every
year.
