1. Subjective/Objective
PJ,29 yo male
CC: Patient complains of constricting, band-like pain around head (temples) approximately 2 times per
week for the past few weeks (attributes to stress of starting new job in nearby city & to his long commute)
Symptoms/Presentation
S: headache pain
C: constricting, band-like headache pain around head
H: has not had problem before, has been happening 2 times per week for the past couple weeks,has not
tried anything for treatment yet
O: symptoms started a couple weeks ago, patient thinks it is due to stress of starting new job in nearby
city and to his long commute
L: symptoms limited to head
A: N/A
R: N/A
Current Medical Conditions
Hypertension, hypercholesteremia
Current Medications
RX: Lisinopril/hydrochlorothiazide 20 mg/25 mg – one tablet once daily – hypertension,
simvastatin 40 mg – one tablet once daily – hypercholesteremia
OTC: none
Medication Allergies/Reaction
No known drug allergies (NKDA)
Social History
Patient denies use of alcohol, tobacco, and caffeine
Appropriate lab/vitals
N/A
Assessment/Triage
Patient candidate for self-care,no MD referralnecessary at this time
Assessment
Patient is a 29 yo male who presents with a constricting band-like pain around his head 2 times a week for
the past few weeks. Patient description of headache symptoms is suggestive of tension headache. Patient
does not have any exclusions for self-treatment and as such, is indicated for self-care with non-opioid
analgesics.
Plan/Triage
Pharmacologic
1. Headache – acetaminophen, 2 tablets every 4-6 hours while symptoms last, do not take more than
10 tablets/24 hours (3,250 mg/24 hours), limit alcohol intake due to increased risk of liver
toxicity/failure if doing so with acetaminophen, do not use more than 3 days/week due to risk of
medication-overuse headache

2. Non-pharmacologic
1. Headache – relaxation exercises,physical therapy emphasizing stretching/strengthening of
head/neck muscles, maintaining regular sleeping/eating/exercising schedules, ice/cold packs
combined with pressure to forehead/temple area, avoiding foods with vasoactive substances (i.e.
caffeine in coffee,theobromines in chocolate, MSG in Asian foods, etc.)
Continue to monitor symptoms. If symptoms worsen through therapy/new symptoms develop/symptoms
do not resolve within 10 days, see doctor.