Case
Shirley Naylor

Subjective Notes
Shirley Naylor is a 35-year-old white female with a history of asthma and irritable bowel syndrome who presents to clinic with a 2 day history of headache. The headache began 2 days ago with the onset of her menstrual period and has become progressively worse. The pain is constant and located in the left temporal region, and she describes it as "throbbing." She has had associated nausea and one episode of vomiting. She also saw "squiggly lines" when the headache was at its worst, but she has had no other visual disturbances. She has taken ibuprofen, but it has provided only minimal relief. There was no trauma, and she denies any fever/chills, photophobia, phonophobia, or history of migraine headaches. She has had headaches associated with her period in the past but not with this intensity or for this duration. Over the past month she has noticed that she has been increasingly tired. She has also had several episodes of lightheadedness, particularly when rising from a sitting postition or with sudden movement. She has noted some posterior headaches/neck pain since cleaning the garage about 1 month ago. She denies any recent weight change, night sweats, hearing changes, lymphadenopathy, weakness, syncope, falls, chest pain, SOB, or changes in bowel or bladder habits. Current medications--Albuterol PRN; Ibuprofen PRN Allergies--NKDA

Objective Notes
Temp: 97.1 P: 72 R: 12 BP: 112/58 Gen: pleasant 35-year-old who appears her stated age. She is alert and oriented and in no acute distress. HEENT: PERRL bilaterally; EOM intact; fundoscopic exam reveals no abnormalities; conjucntiva s erythema/exudate; TMs and external auditory canals clear; hearing non-impaired; oral and nasal mucosa pink and moist; tongue and uvula midline; pharnyx s erythema or exudate. Neck: supple; non-tender; no lymphadenopathy or thyromegaly CV: normal S1/S2, RRR, no murmurs, gallops, rubs NM: strength grossly intact upper and lower extremities Ext: no cyanosis, clubbing, edema

Assessment Notes
1. Headache-history suggestive of migraine but cannot rule out comorbid muscle tension headaches. 2. Fatigue--concerned about anemia or thyroid disease 3. Asthma--stable on PRN albuterol 4. IBS--stable

Plan Notes
1. Provide Rx for migraine abortive therapy (summatriptan) as well as stronger pain control (800 mg ibuprofen) 2. CBC, BMP, TSH, ESR 3. Follow-up in 2-3 months or sooner if symptoms progress/do not resolve. If no improvement will pursue more aggressive investigation 4. Continue Albuterol PRN 5. Health Maintainence--discuss age related screenings/preventions and well-woman care at next visit

Labs
1. 	Complete Blood Count with Differential (CBC)		2. 	TSH	
3. 	BMP		4. 	Erythrocyte Sedimentation Rate (ESR)	
5. 	Glucose, Random		6. 	Sodium, Na (Blood)	
7. 	Potassium, K (Blood)		8. 	Creatinine (Blood)	
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