I Human Case Week #9 26-Year Old Female With
Frequent Severe Headache
,PATIENT DETAILS
• Name
• Age: 26 years old
• Height: 5'6" (168 cm)
• Weight: 122 lbs. (55.5 kg)
• Location: Outpatient clinic
• Reason for Encounter: More frequent severe
headaches
PATIENT DETAILS
• Name: [Insert Patient Name]
• Age: 26 years old
• Gender: Female
• Height: 5'6" (168 cm)
• Weight: 122 lbs. (55.5 kg)
• Location: Outpatient clinic
• Reason for Encounter: Increased frequency and
severity of headaches
, PHYSICAL EXAM FINDINGS
• General Appearance: The patient appears alert
and oriented, well-nourished, but in mild
discomfort due to the headache. No acute
distress.
• Vital Signs:
o Blood Pressure: 118/76 mmHg o
Heart Rate: 72 bpm o Respiratory
Rate: 16 breaths/min o Temperature:
98.6°F (37°C) o Oxygen
Saturation: 99% on room
air
• HEENT:
o Head: Norm cephalic, atraumatic.
o Eyes: No evidence of scleral icterus or
conjunctival injection. Extraocular
movement is intact; pupil is equal, round,
reactive to light (PERRL). No papilledema
observed on fundoscopic exam.
o Ears/Nose/Throat: No sinus tenderness.
Tympanic membranes intact bilaterally. No
oropharyngeal lesions or exudates.
• Neck:
Frequent Severe Headache
,PATIENT DETAILS
• Name
• Age: 26 years old
• Height: 5'6" (168 cm)
• Weight: 122 lbs. (55.5 kg)
• Location: Outpatient clinic
• Reason for Encounter: More frequent severe
headaches
PATIENT DETAILS
• Name: [Insert Patient Name]
• Age: 26 years old
• Gender: Female
• Height: 5'6" (168 cm)
• Weight: 122 lbs. (55.5 kg)
• Location: Outpatient clinic
• Reason for Encounter: Increased frequency and
severity of headaches
, PHYSICAL EXAM FINDINGS
• General Appearance: The patient appears alert
and oriented, well-nourished, but in mild
discomfort due to the headache. No acute
distress.
• Vital Signs:
o Blood Pressure: 118/76 mmHg o
Heart Rate: 72 bpm o Respiratory
Rate: 16 breaths/min o Temperature:
98.6°F (37°C) o Oxygen
Saturation: 99% on room
air
• HEENT:
o Head: Norm cephalic, atraumatic.
o Eyes: No evidence of scleral icterus or
conjunctival injection. Extraocular
movement is intact; pupil is equal, round,
reactive to light (PERRL). No papilledema
observed on fundoscopic exam.
o Ears/Nose/Throat: No sinus tenderness.
Tympanic membranes intact bilaterally. No
oropharyngeal lesions or exudates.
• Neck:
