Case Report: Chief Complaint

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Subjective Data
Chief Complaint (CC):
The patient is a 35-year-old woman with a complaint of frequent headaches occurring over the past two weeks.
History of Present Illness (HPI):
The patient reports that she has never had issues with headaches prior to two weeks ago. She states she may have a headache after a stressful day; however, denies premenstrual headaches or frequent headaches. The patient reports the headaches started two weeks ago, occurring 3-5 times per week. The headaches are on the left side in the temporal area, throbbing, and severe, a 7 on a scale on 1-10, with no radiation reported. The patient reports some nausea with the headache and at times seeing “spots in front of her eyes” right before the onset of the headache. The headaches last for several hours and are relieved if she is able to get some sleep. She has tried Ibuprofen with no relief. She reports she retreats to a dark and quiet corner when the headaches start. The patient reports no trouble with her vision, no epistaxis, no upper respiratory symptoms, or sinus issues. She
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While this individual is in the clinic, it is imperative to review her spiritual, social, psychological, and cultural well-being. This allows the provider to take a holistic approach in treating this individual by reviewing immunizations, activity levels, dietary intake, and stress factors. This allows the practitioner to identify areas for improvement and potential needs for follow up for this individual. It would also be prudent to review risk factors, screening needs, and modifiable factors including weight, social habits, diet, and lifestyle choices. From this information, a plan for health and illness prevention can be determined. By taking, an active approach in the development and identification of patient healthcare needs can drastically decrease mortality and morbidity leading to a long, healthy life (Dunphy et al.,
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