Case
Shirley Naylor

Subjective Notes
S.N., a 35 yo white female with a history of asthma, presents to the clinic with a headache. This headache has been going on for two days continuously. The pain is described as throbbing and located in the left temple. Px reports altered visual sensation described as squiggly lines immediately preceding the headache. These visual symptoms resolved within the first hour. The pain has decreased a little since the onset of the headache. Px describes associated nausea which continues and vomiting which provided some relief and has since resolved. Patient reports that Advil made the pain a little better. Patient also started menstruation on Monday (the day of onset). Patient has never had anything like this before, and no one in her family has had similar symptoms. Px reports no event preceding the headache that may have triggered it, including injury to head, consumption of cheese, chocolate and/or wine. Px also reports feelings of fatigue for the past one month. Px takes albuterol inhaler prn for asthma and has had no current asthma attacks. Px started Celexa approximately 3 monthes ago then self-discontinued after a couple weeks. Px takes no other medications. Px has NKDA. Px does not smoke tobacco, use alcohol, or use recreational drugs. Px has previous diagnoses of irritable bowel syndrome, which she says she has no symptomology of currently. Previous diagnosis of depressed mood for which she has no current symptomology. G2,P2,0,0,2 No positive findings on review of systems that seem pertinent to current findings. Px does report tingling in legs when sitting on toilet, but not while sitting anywhere else. She reports no difficulty in raising self from toilet or walking after this. No surgeries or hospitalizations except for the births of her children.

Objective Notes
Px is alert and oriented x3. Px appears in no apparent distress. Vitals Temp 97.1 F, Pulse 72, Resp. 12, BP 112/58. PERRLA. Visual accuity is 20/10 using both eyes. Head: No apparent deformity or lesions. No palpable mass in the left temporal region. Lymph Nodes: No enlarged submandibular, supraclavicular, or sublingual lymph nodes. Heart and Vascular: S1 and S2 heard on auscultation with no extra sounds or murmurs. No carotid bruits appreciated bilaterally Lungs: Breath sounds clear and without wheeze, or rhonchi bilaterally. Abdomen: Bowel sounds heard in all four quadrants. No areas of pulsations or heaves. No tenderness to palpation. No apparent masses or organomegaly.

Assessment Notes
Headache of two day duration r/o migraines temporal arteritis mass effect vascular abnormality Nausea probably secondary to headache Asthma, patient complains of no current symptoms or problems, uses Albuterol inhaler prn. Fatigue of one month duration r/o anemia hypothyroidism Sensory phenomena during bathroom use Currently menstruating 

Plan Notes
Outpatient Administer migraine medication. Do routine lab work to rule out unusualy etiology Chem 7 CBC TSH UA ESR Consider CT if migraine medication fails to work and headache with nausea persists past end of menstrual period. Follow-up if symptoms persist or reoccur. Follow-up regarding sensory phenomena in legs.

Labs
1. 	Abdomen (CT scan)		2. 	TSH	
3. 	Sedimentation Rate (Westergren, ESR)		4. 	Complete Blood Count with Differential (CBC)	
5. 	UA		6. 	Sodium, Na (Blood)	
7. 	Chloride, Cl (Blood)		8. 	Potassium, K (Blood)	
9. 	Carbon Dioxide Content, CO2		10. 	Glucose, Random	
11. 	BUN		12. 	Creatinine (Blood)	
13. 			14. 		
15.