Case:  Shirley Naylor

Subjective Notes
35 y/o female with a pmhx significant for asthma, IBS presents to clinic today for headache,fatigue, dizziness. Headache- 3 day h/o throbbing headache (4/10)that is located over the left temporal area. The pain started at this location without any radiation. She has no associated symptoms except for some occasional nausea, and she vomitted once on the day of onset. On further questioning, she does mention some squiggly lines with her vision 3 days ago, but has since resolved. No aggravating factors; although, she does mention that some of her regular menses occur at the same time as some of her headaches. This headache did occur with the onset of her latest menstrual cycle. Advil taken as directed helps some. Patient also, mentions that 4 days ago she experienced a headache located over the occiput after strenuous activity (cleaning her garage). This pain has since resolved. There has been no associated neurological symptoms or previous trauma. The patient states no stressors in her life at this time. She is happily married (second marriage) and has two children (9 & 12). 6 months ago, she was on an antidepressant for situational depression. She took the medcation for a few months, but has since stopped since the employee causing her stress is no longer at her work place. Fatigue- One month history of fatigue, the patient has not been sick lately. She has been sleeping her usual amount of hours per night (6-8). There has been no increase in work hours or demand in performance at work. No increase in family demands of her time. No weight changes, shakiness, diarrhea, constipation, palpitations, SOB, chest pain. Regular menses- no heavy flow, spotting, irregularities. Dizziness- Onset 1 month ago. Dizziness lasts for several seconds to minutes. No tinnitus or fullness sensation. Aggravated by quick movements. Relieved by rest. No hearing changes. No allergies/ recent infections. Only other neurological finding is both legs fall asleep withing 30 seconds after sitting on the toilet. No problems with sitting in other places or exercising. Rest of review of systems negative.

Objective Notes
VSS General- A and A, NAD, well nourished, pleasant HEENT- atraumatic scalp, no tmj tenderness, TMs clear, nasal mucosa pink and moist. PERRLA. Oral mucosa pink and moist. Neck- no adenopathy or thyromegaly FROM, mild tenderness over right trapzius muscle Lungs- CTA B No adventious sounds CV- RRR without murmur AB- Pos BS soft NT ND, no guarding/rebound gu-deferred gi-rectal deffered Neuro/MS - strength 5/5 DTR 2/4 no clonus FROM all extremities 2+ pulses CN II- XII without asymmetry or deficits 

Assessment Notes
Headache Fatigue Dizziness B leg numbness/tingling

Plan Notes
Headache- advil prn RX Ibuprofen 600mg one tab po q6hrs prn #40 RF1 Observation, if cont or gets worse, will consider imaging If any development of other neurologic symptoms, then CT/ MRI Fatigue- order cbc, bmp, tsh further rec's pending results Dizziness- BPV reassurance, observation for increasing symptoms consider meclizine prn B leg numbness/ tingling Observation for now, no current neurologic or muscular complaints at this time RTC prn

Labs
1. 	Complete Blood Count with Differential (CBC)		2. 	bmp	
3. 	tsh		4. 	Sodium, Na (Blood)	
5. 	Potassium, K (Blood)		6. 	Glucose, Random	
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