Case
Shirley Naylor

Subjective Notes
35 yo white female c/o HA x 2 days, along with fatigue and lightheadedness x 1 month. Her HA began suddenly in AM on 1/27/03, described as a sudden throbbing pain on L side of head, rated 7 out of 10. Associated with n/v. Reports seeing "squiggly lines" at onset, but otherwise vision unimpaired. Has been taking Advil PRN, which is helping minimally. She has never had a HA of this intensity or duration before, although she does c/o mild HA when having menses, and she is currently on her menses. No sleep disturbance. Denies FamHx of HA/migraines. Also reports feeling very fatigued over x 1 month. Exhausted throughout the day. No change in sleep pattern -- no trouble with sleep onset or staying asleep. Also reports lightheadedness upon standing x 1 month. Has never fallen or lost consciousness. However, sometimes feels unsteady upon standing, thus requiring her to rise slowly and/or to hold onto nearby stationary objects for support. ROS: Gen = denies change in appetite/sleep, + fatigue. HEENT = + HA, + scotomata, denies tinnitus/dysphagia/odynophagia. Resp = denies SOB. CV = denies CP/palpitations. Abd = + n/v, denies hematemesis/diarrhea/constipation/BRBPR/abd pain. GU = currently on menses, no change in menstrual cycle, denies dysuria/hematuria. Neuro = + HA, + lightheadedness upon standing, + tingling sensation in legs only when seated on toilet, otherwise denies numbness/tingling/weakness. PMHx: 1. asthma - intermittently uses inhaler 2. IBS - dx'd in 20's, no problems lately 3. depression - dx'd last summer, on Celexa x 2 months, stopped taking rx in 10/2002 against advice of MD. Allergies: NKDA Current Meds: Advil PRN, albuterol MDI PRN SocHx: lives in SPI, married x 5 yrs, going well, 2 children from previous marriage (divorce), works in Real Estate business x 10 yrs, enjoys.

Objective Notes
VS = 97.1 72 12 112/58 Gen = pleasant, NAD, cooperative HEENT = NC/AT, no tenderness to palpation, EOMI, PERRLA, non-icteric sclerae, nl conjunctivae, TM's clear bilat, nl oropharynx Neck = no lymphadenopathy/thyromegaly Lungs = CTA bilat CV = nl s1s2, reg rate, no s3/s4/murmur Abd = + BS, s/nt/nd, no masses 

Assessment Notes
35 yo white female with: 1. HA x 2 days = likely migraine HA given n/v/throbbing/unilateral/visual images 2. fatigue x 1 month = hypothyroidism vs depression vs anemia 3. lightheadedness x 1 month = dehydration vs anemia vs cardiac rhythm disturbance vs near-vagal syncope

Plan Notes
1. HA = may try Excedrin Migraine (has caffeine in it), if no help may try advancing to Imitrex. = provide reassurance. 2. fatigue = labs: CBC, TSH = provide reassurance, encourage continued good sleep hygiene, encourage adequate PO fluid intake. 3. lightheadedness = labs: CBC, BMP, EKG = provide reassurance, encourage continued utilization of supports to keep from falling, encourage adequate PO fluid intake.

Labs
1. 	Complete Blood Count with Differential (CBC)		2. 	TSH	
3. 	BMP		4. 	EKG with Rhythm Strip	
5. 	Glucose, Random		6. 	BUN	
7. 			8. 	Creatinine (Blood)	
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15.