History of Present Illness
APA format 3 peer references and response needs to agree or disagree with differential diagnosis and explain why
Week 9: Review of case study 1
Patient Initials: _AS__ Age: __20___ Gender: __M_
SUBJECTIVE DATA:
Chief Complaint (CC): an Unbearable headache
History of Present Illness (HPI): 20-year-old Caucasian male presented with a chief complaint of intermittent headaches. The patient reports that a headache is so bad and unrelenting that he feels it in his eyes with great intensity, nose, cheekbones, and jaw. The patient states “The headache ache comes and goes.” The patient reported that his headache started two days ago and had increased in severity of a 10/10 on the pain scale as the pressure in the eyes creating the sensitivity to light, the feeling of having toothache makes it too hard to bear. While the patient was not able to pinpoint when his headache started, he reports that he was so overwhelmed with school and work over the past couple of weeks, it may have precipitated the headache. The patient reporting taking Tylenol which is ineffective; he has tried to get more sleep and use dimmed lights while awake. He states, “while the sleeping for a longer time helps a little, the headaches return as the day progress and gradually gets worse with each passing minute. The only thing that stops the headache is passing time.”.
Medications: Tylenol 650 mg every 4 to 6 hours.
Allergies: Ibuprofen- angioedema
Past Medical History (PMH): Mumps -resolved
Past Surgical History (PSH): Appendectomy at age 16 due to a ruptured appendix.
Sexual/Reproductive History: Not sexually active.
Personal/Social History: Reports going to church on Saturdays (worship sunset to sunset), Saturday after sabbath worship; sometimes going bowling or roller skating and socializes with peers from church or school. Denies tobacco use, alcohol use, and drug use. Patient reports at least three mornings per week approximately one hour of exercise at the work gym.
Immunization History: reports immunization up to date and will get his annual flu shot at work October 25, 2018.
Significant Family History: grandfather died one year ago (72) from heart failure. Grandmother 68 alive and living with hypertension.
Lifestyle: Patient is newly as a mental health counselor at a hospital psychiatric unit. He just started studying law part-time at the local university; current course is online. He currently lives alone in a two-bedroom apartment, as parents live in another country. His support system is his family who is a phone call away, and his best friend who lives 20 minutes away from his home. He does not drink, smoke or do drugs. He attends church on Saturday. Socializes with church friends and or best friend after sunset some Saturday at the local bowling alley, skating rink, or “hang out” at a local diner. Currently is not involved in a relationship and is not sexually active.
