Comprehensive iHuman Case Analysis: Migraine With Aura in a 26-Year-Old Female With Laboratory Capabilities. WEEK #7 Walden University

Patient Profile

• Name: (Virtual Patient)

• Age: 26 years

• Sex: Female

• Height: 5'6" (168 cm)

• Weight: 122 lb (55.5 kg)

• BMI: ~19.7 kg/m²

• Setting: Primary Care / Outpatient Clinic

• Reason for Encounter: More frequent severe headaches

Chief Complaint (CC)

“I’ve been getting headaches more often, and they’re really severe.”

History of Present Illness (HPI)

The patient is a 26-year-old female who presents with recurrent severe headaches that have increased in frequency and intensity over the past 3 months. She reports headaches occurring 2–3 times per week, lasting 4–24 hours. Pain is described as throbbing and unilateral, most commonly over the right temporal region, occasionally bilateral. Severity is rated 8/10 at worst.

Headaches are often preceded by visual disturbances described as flashing lights and zig-zag lines lasting ~20 minutes. Associated symptoms include photophobia, phonophobia,

nausea, and occasional vomiting. Symptoms worsen with physical activity and improve with rest in a dark, quiet room.

She has been using OTC ibuprofen and acetaminophen with partial relief. No recent head trauma, fever, neck stiffness, focal weakness, speech difficulty, or loss of consciousness. She denies headaches waking her from sleep.

Triggers identified include stress, skipped meals, lack of sleep, and menstrual periods.

Review of Systems (ROS)

General: Denies fever, chills, weight loss

HEENT:

• Head: Positive for recurrent headaches

• Eyes: Positive for photophobia, visual aura; no vision loss

• Ears: No tinnitus or hearing loss

• Nose/Sinuses: No congestion or sinus pain

• Throat: No sore throat

Neurologic:

• Positive for headache and visual aura

• Denies weakness, numbness, dizziness, syncope, seizures

GI: Positive for nausea and occasional vomiting during headaches

Cardiovascular: Denies chest pain, palpitations

Respiratory: Denies shortness of breath

Musculoskeletal: Denies neck stiffness

Psychiatric: Reports increased stress; no anxiety or depression diagnosis

Past Medical History (PMH)

• Migraine headaches (self-reported, no prior formal

diagnosis)

• No chronic medical conditions

Past Surgical History (PSH)

• None

Medications

• Ibuprofen 400–600 mg PRN headaches

• Acetaminophen 500 mg PRN headaches

• Combined oral contraceptive pill

Allergies

• No known drug allergies (NKDA)

Family History (FH)

• Mother: History of migraines

• Father: Hyp