Case
Shirley Naylor

Subjective Notes
The patient is a 35 year-old Caucasian female with a PMH significant for asthma, irritable bowel syndrome, and depressive episode. Her chief complaint today is new onset of a headache two days ago. She awoke in the am with a headache that was located over her left temporal area. It had a dull throbbing quality and increased in intensity accompanied by dizziness until she vomited. She vomited once and felt relief afterwards. Her headache has persisted albeit at a lower intensity, is relieved but not alleviated by 400mg of Advil. She also describes visual disturbance in her left eye like "paisleys", but denies seeing flashing lights or other types of aura. She denies a pressure like band around her head and denies a sharp pain behind her left eye. She also states that she has been tired for the last month. Denies myalgias. She is currently taking an Albuterol inhaler for asthma, has NKDA, not surgical hx, no travel hx, was treated with Celexa for depression for several moths and stopped Celexa electively three months previously. She lives in Springfield with her husband and two biological children. She does not use tobacco, alcohol, or other drugs. Her FMH is positive for asthma and rheimatod arthritis, no hx of cancer, heart disease, or diabetes mellitus. 

Objective Notes
vts T 97.1, P 72, R 12, BP 112/58 General: moderately obese female in no acute distress Neuro: CN II-XII grossly intact, dizzy on rapid movement Gait and station: normal pace and balance on gait, negative Rhomberg test

Assessment Notes
35 yo Caucasian female with hx of depression, Irritable bowel syndrome, asthma with new onset of headache with visual disturbance in left eye. This could be a new onset of a migraie headache, could be related to a space occupying lesion in left tempoparietal distribution, or may be related to depressive symptomology. 

Plan 
The patient was sent home with prescription of Sumitriptan for migriane headaches with a follow up appoint ment set for one week. If the headache became much worse she was instructed to call prior to the one week follow up visit. Keeping in mind the possiblity of space occupying lesion, may consider MRI on next evaluation. Fatigue may be related to depressive symptoms or may be related to anemia or infectious etiology. Thus a CBC was ordered and will be read to her at the next follow up visit. 

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