Description

Problem Statement – Version 1

Perry Soloman, 26yr old female with self-reported 10yr history of headaches, presents to the clinic for increase in headache frequency and severity for last two months. She reports headaches preceded by visual auras, are accompanied by nausea and vomiting, are aggravated by light and noise, and alleviated by dark, quiet, and sleep. She denies head trauma or accidents.

Physical examination revealed atraumatic head, normal neurological and abdominal examination without abnormalities, elastic skin turgor.

Problem Statement – Version 2

P.S. is a 26-year-old female graduate student who works part-time waitressing. Headaches range in severity of 2-3/10 up to 8-10/10 lasting up to 15 hours. Reports experiencing headaches since 10 years of age. Headaches are associated with nausea, vomiting, photophobia, and phonophobia. Denies any head/bodily traumas or injuries. Headaches are relieved with OTC Acetaminophen 325-650 mg or ibuprofen 200-400 mg as needed and with sleep, quiet, and darkness. Reports Mother has experienced similar headaches. Reports stress related to work and school.