Case
Shirley Naylor

Subjective Notes
cc: L sided head ache x2 days hpi: 35y/o cfemale with a past medical histort significant for asthma, and irritable bowel in her 20's presents with a l temporal HA x2 days./ Pt. states that she woke up two days ago with a throbbing -headache on the left side and stated the pain at that time was a 7-8/10. she said that the pain lasted one hour then she vomitted and the pain improved to a 4-5/10 and has remained so until now. she states that she took advil q4hrs. with mild relief only. she states that she started her period recently also. and has had headaches in the past associated with her periods. she states having fatigu, and and dizziness on standing from a sitting position. pt. denies any fever, weakness, c.p., s.o.b, any new stresses, photosensitivity, vision changes. no change in sleep, appetite, bowel or bladder habits. she did state that she noticed that her legs fall asleep - but only when she is on the toilet. she did also state seeing "squiggly" lines when her HA first came on , but has had no similar occurances since. No recent viral illnesses stated pmh; asthma- since childhood irritable bowel in 20's - no recurrance psurghx; none meds: albuterol mdi, advil recently fh; sig for RA, Asthma SocHx: denies tobacco, etoh, or drug use 2cups of coffe q/day, no soda, no chocolate occupation:real estate Ros: See hpi for sig ROS -

Objective Notes
Vital signs stable Lungs: CTAB Heart: s1s2 + no m/r/g/ rrr Abd:+BS soft nontender Neuro: CN 2-12 grossly intact/strength5/5/reflexes+2 patellar bilat rhombergs - : no past pointing : mid tenderness on palp of L-temporal area

Assessment Notes
1. HA - atypical migrane vs. sah vs. temporal arteritis, vs avm vs. viral syndrome 2.fatigue - anemia 3.dizziness - anemia - poss postural hypotension

Plan Notes
1. labs - check for anemia and work up as needed trial of higher dose nsaid, mri if continues to have ha despite therapy, check esr - pt. does not appear to have any focal neuro deficits. check postural bp's 2. check cbc, hemocult 3. check postural bp's 

Labs
1. 	Complete Blood Count with Differential (CBC)		2. 	tsh	
3. 	Erythrocyte Sedimentation Rate (ESR)		4. 	bmp	
5. 	hemocult		6. 	Potassium, K (Blood)	
7. 	Sodium, Na (Blood)		8. 	Glucose, Random	
9. 	Creatinine (Blood)		10. 	BUN	
11. 			12. 		
13. 			14. 		
15.