Subjective

CC: “Headache”
HPI: 21 yo female presents with a headache that with severe, painful pounding behind her right
eye that she states is a 9/10 on pain scale. This has been going on for a few weeks and she has
had to stay in bed often due to pain. The pain lasts from hours to days and occurs multiple times
a week. Nothing seems to make the pain better but lying in bed helps her tolerate pain.\

PMH: none
PSH: tonsillectomy age 10
Hosp: tonsillectomy

Meds:
Rx: none
OTC: Motrin, handful couple times a day
Vitamins: None

Allergies:
Rx: none
Food: none
Environment: grass- itching w/ rash

SH:
Alcohol: cocktail once a month
Tobacco: none
Illicit: none
Social: drug rep, single lives alone

FH:
Mother: none
Father: none
Siblings: None, 2 sisters age 25 & 18

ROS:
Const: neg fevers, chills, night sweats, weight gain/loss pos fatigue- weakness from pain
HEENT: pos headache, blurry vision, floaters, photosensitivity, neg eye pain, nose discharge
Cardio: neg palps, chest pain, syncope
Nuero: neg numbness, tingling, memory loss

Objective
Vitals: BP: 138/78 RR: 21 P: 95 T: 98.9 BMI: 25
PE:
General: no ill appearing, appears to be mildly in distress secondary to pain
HEENT:
Head: normocephalic, atraumatic with symmetrical facial features
Eyes: Snellen vision 20/20 bilat uncorrected, white sclera, pink conjunctiva, extraocular muscles
intact
Cardio: no carotid bruits, 2+ carotid bilat, regular rhythms no bruits, gallops, murmurs,
Nuero: Alert & oriented X4, CN 1-11 intact, no motor/sensory deficits UE/LE

Assessment
1. Rebound headache – consuming too much Motrin
2. Tension headache
3. Cluster headache
4. Headache due to vison problems

Plan
Explain to pt about rebound headaches and halt taking excessive amounts of Motrin, switch to
ibuprofen or Advil 500 mg QD, encourage mild exercise to help relieve eye pain . Return in 1
week if pain persists, consider making appointment with optometrist to check for vision issues