Complete Health History
BIOGRAPHIC INFORMATION
- Patient’s Name:
- Address: Maiden Street
- Gender: Male
- DOB: 220/02/1990
- Place of Birth: Montgomery
- Race: Caucasian
- Ethnicity: English
- Education level: Bachelors
- Occupation: Inventory Clerk
- Support persons: mother, siblings
SOURCE AND RELIABILITY
- Primary and reliable
CHIEF COMPLAINT
- Headache
HISTORY OF PRESENTING ILLNESS (HPI)
- A severe headache for the past four hours. Can feel the pulse in temples, 4 on a scale of 1-10, onset during the lunch break at work. The pain is a throbbing sensation in the temporal region. He also noted nausea and light sensitivity. Patient reports less severe headaches less than twice weekly. The is no significant change in the frequency of his headache. The patient does not know of any aggravating factors. Ibuprofen and rest in the dark. No symptoms of fever, neck pain, or hearing loss.
MEDICATION
- Herbal: none
- OVC: Paracetamol, (last 6 months)
PAST MEDICAL HISTORY
- General State of Health: Good
- Past Illness: None
- Chronic Illnesses: minor scoliosis (no pain or limitation)
- Hospitalization: None
- Surgeries: Tonsillectomy
- Active/Chronic Problems: Sports-induced asthma; not being treated
- Allergies: No known allergy
- Substance abuse: No tobacco use, drinks alcohols twice a week
- Recreational drugs: None
- Nutrition: Neither overly unhealthy nor healthy
- Sleep Pattern: Tries for six hours every night; short nap after lunch at least three times a week.
- Exercise: running in the morning three times a week; does gymnastics weekly.
MEDICATION HISTORY
- Current medication: None
- Vitamins: No, there is need for
- Herbal remedies/health supplements: None
- Past medication: diclofenac, d/c’d 6 months ago
- Dose: 2 to 3 tablets a day as needed
- Reason for taking: fractured limb
- Reason for d/c: treatment periods elapsed
Health Maintenance
- Childhood illness: no hospitalization reported, flu, malaria
- Immunization: Flu vaccine yearly, Yellow fever, 2008
- Surgeries: tonsillectomy
- Accident: no history
- Prolonged pain: none, just the recurrent headache
- Allergies: dust, pollen
ENVIRONMENTAL HEALTH
- Occupation: Inventory Clerk: Eastland canners
- Nature of work: hours weekly, various roles, compliance, supervision, and dispatch.
- Work setting: office building, sun, factory, welding, cafeteria
- Exposure to hazardous material and loud noise: yes
- Hobbies: rugby, socializing, watching movies
- Work-related symptoms: occasional headache, no treatment
- Travel history: UK, Ital, East Africa, throughout USA, Caribbean
FAMILY HISTORY
The patient was raised by both parents in a family of four. He has two sisters and one brother; all alive and healthy The father passed on five years ago in a car crash aged 73. The mother is still alive and healthy. The patient is single and is dating. No history of diabetes and hypertension.
PERSONAL SOCIAL HISTORY
- Tell me about yourself: gentle, happy, a jovial personality, no suicidal thoughts, moderate stress level
- Typical day: normal day routine at work 8 hours for 6 days.
- Meals: takes 2-3 meals in a day. Purchases food from a local store. Does not follow any special diet
- Sleep pattern: tried six hours daily, regular naps after lunch break
- Self-care: tries to exercise at least thrice a week, bike riding and rock climbing
- Drugs, Alcohol, or smoking: no illegal drug use or tobacco use. Seldom alcohol use.
REVIEW OF THE SYSTEMS
- Constitutional symptoms (fever, weight loss, etc.): negative
- Eyes: positive
- Ears, Nose, Mouth: negative
- Cardiovascular: negative
- Respiratory: negative
- Gastrointestinal: negative
- Genitourinary: negative
- Musculoskeletal: negative
- Integumentary: negative
- Neurological: negative except headaches
- Psychiatric: negative
- Endocrine: negative
- Hematologic/Lymphatic: negative except low iron levels; still within healthy limits
- Allergic/Immunologic: negative
ROS OF SPECIFIC HPI
Recurrent primary headache with no underlying structural problems or underlying disease presenting with a migraine. Pulsing head pains, photophobia, and nausea. During migraine, the temporal artery enlarges and dilates. The rapid contraction and expansion cause the nerves around the temporal artery to stretch releasing chemicals that result in inflammation and pain. Continued enlargement increases the intensity of pain.