Patient Initials: B.P. Gender: Male Age: 20 years Race: White
Subjective:
CC: “I have intermittent headaches which also radiate to the jaws, cheekbones, and the nose.”
HPI: B.P. is a 20-year-old male patient who has come to the hospital for the first time unaccompanied. According to B.P., he has been having intermittent headaches for the past one week. He feels the pain all over his head. However, he feels the intensity and pressure of the headache above the eyes. B.P. further indicates that the headache also scatters to the cheekbones, nose, and jaw.
Location: Head
Onset: One week
Character: A throbbing pain that is localized above the eyes and scatters all over the head.
Associated signs and symptoms: Headache that spread to the bones of the cheekbones, the jaws, and the nose.
Timing: Intermittent
Exacerbating/ relieving factors: Nothing has been found to exacerbate or relieve the headache.
Severity: 8/10 on the pain scale.
Current Medications: None.
Allergies: No known food or drug allergies reported.
Past Medical History: B.P.’s medical records indicate that he received all immunizations according to schedule. His last tetanus vaccine was two weeks ago when he had a wound on his right leg. B.P. denies previous hospitalizations or being diagnosed with a serious medical condition. He cannot remember whether he has ever been treated of common childhood diseases such as malaria and pneumonia.
Social History: B.P. loves football, cycling, and swimming. He goes swimming every weekend and likes to read novels during his free time. His father is an accountant and his mother is a nurse. Both of them are employed and they go to work in a nearby city every day. B.P. denies consuming cigarettes, alcohol, or illicit drugs.
Family History: Both maternal and paternal grandparents are still alive. Maternal grandmother has diabetes and his paternal grandfather has high blood pressure. B.P. does not know the ages of his grandparents. His mother, father, and two sisters are alive and they have not been diagnosed with a serious medical condition.
Review of Systems:
General: Denies fever, chills, or nausea.
HEENT: B.P. denies a history of physical head injury. However, he reports intermittent headaches which diffuse all over his head and scatter to the jaw, cheekbone, and nose. B.P. does not report any problems with hearing or vision. He does not report a runny nose. Reports a headache that spreads to the nose. Denies a sore throat.
Neck: Does not report pain in the neck region. Reports headaches that spread to the jaws and cheekbone.
Cardiovascular/Peripheral Vascular: Denies tightness of the chest. Does not report palpitations and denies chest pain.
Respiratory: B.P. denies chest congestion or breathing difficulties.
Gastrointestinal: Reports no abdominal pain, constipation, indigestion, abdominal swelling, or abnormal bowel movements.
Genitourinary: Report no abnormal urination frequency. B.P. denies changes in urine volume.
Neurological: Reports intermittent headaches which spread all over the head and radiate to the nose, cheekbones, and jaws. Denies numbness of fingers and toes. Does not report heat or cold intolerance.
Musculoskeletal: Does not report joint pain or movement/walking difficulties.
Skin: B.P. denies skin itchiness, redness, or rashes on the skin.
Psychiatric: B.P. does not report mental health problems and denies a history of anxiety, post-traumatic stress disorder, or depression.
Hematologic: Denies sickle cell disease. Denies a history of anemia or other blood disorders.
Endocrine: Does not report abnormal night sweats or thyroid issues.
Allergic/Immunologic: No known allergies reported.
Objective:
General: B.P. is oriented to time, place, and person. He is well groomed and attentive.
Vital Signs: BP 110/85, T 98.6F, weight 113 lb, heart rate: 92 beats
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