Case
Shirley Naylor

Subjective Notes
CC HA HPI Pt is 35 yo WF who came in the clinic for HA for 2 days. She states she started HA 2 days ago, throbbing, left side temporal area, 7-8/10,non raditaion,assosiated with nausea,vomiting, bulerrd vision,alleviated by Advil,which is taking QID, some help,but not all, HA came down to 4/10. She has been legs tinglings for a month when she goes to the bathroom,other situation don't cause pain, like sitting the chair or driving a car.not worse, not recent trauma. PMHx Asthma taking Albu inhaler Allergy NKDA Meds advil, albu FMHx father Asthma,Mother,RA, no hx of HTN,DM,CVA,CAD,Migraine SHx no smoking,no ETOH,no drug use, marrige, 2 kids, living springfield with hushand, 2 kids OB,GYN G2P2 period regulrar, pap normal done last year,sexually active,no hx of STD, ROS no Wt change, no weakness, +fatige, no vision problem,no hearing problem,no sob, no CP, no cough,no sore throat, no fever,chills, sweating,no abd pain, no diarrhea, no constipation,no leg swelling. 

Objective Notes
PE t 97.1, pluse 72 rr 12 BP 112/58 Gen alert and oriented times 3, non acute distress, HEENT NC/AT,PERRLA,non tenderness on temporal aere bilateral, no erythema,no extudate in mouth, no nasal discharge. Neck, supple no lymphadenopathy CV RRR no murmurs Resp clear to auscultation bilateral Abd NT, ND, BS+, soft MS 5/5 all flexoer and extensor in lower legs, sensation intact to dull and sharp, DTR intact bilateral, SLRT negative bilateral 

Assessment Notes
1. HA DDx Migarine vs tension HA, Pt is associated with N/V,bullered vision, not apparent tenderness on left temporal area,no current stress or apparent etiology,possibly Migrine 2. Legs tinglings unkonwn cause, no hx of traum, only it occurs in the bathroom.PE is grossly intact of mascle strength,senstain, reglex,DDx radiculopathy vs disc hernia vs muscle strain vs legament strain vs some nerve conduction problem.

Plan Notes
1 will give NSAID as prescribtion med, such as long acting,naproxyn. if symptom not improve, or get worse, return to clinic, otherwise, follow up 3 mons 2 continue closely observe symptom, if it get worse, or still appear for a month, may need futher work up. 3 screening pap smere, memmogram need every year

Labs
1. 	Complete Blood Count with Differential (CBC)		2. 		
3. 	Peripheral Blood Smear		4. 		
5. 	Biopsy and Aspirate- Bone Marrow		6. 		
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