CC More frequent severe headache
HPI: Beth Brown is a 16 y/o female who presented with unilateral headaches for
more than ten weeks ago with increase in frequency, nausea and vomit. Patient
states that the pain is on
...
CC More frequent severe headache
HPI: Beth Brown is a 16 y/o female who presented with unilateral headaches for
more than ten weeks ago with increase in frequency, nausea and vomit. Patient
states that the pain is on the left side the head and it feels like it is behind patient’s
eye. When the pain starts is like 2-3 and increases to 8-10 in intensity (0-10 pain
scale), the pain feels like intense/throbbing and it last for 15 hours with a frequency
of every week, and there is no associated symptoms. Patient states that before the
pain starts she has visual aura “visual distortions, blurry wiggly stuff at the edges of
my vision”. Aggravating factors are bright lights and loud noises; it helps if patient
lies down in a dark room and try to sleep it off. Patient also noticed that the pain
also starts when she eats junk food or chocolate. The pain is interfering with her
school and activities of daily living. Patient has tried over the counter pain relievers
as well as cool cloth and dark room, but they don't relieve the pain. Patient denies
nausea, vomit, diarrhea, blurred vision, dizziness, shortness of breath or chest pain.
Current Medications: No prescription medications. Over the counter Tylenol, Advil.
Allergies: No known allergies.
Pertinent PMHx: Patient is up to date with her childhood immunizations.
Soc Hx: Patient denies alcohol intake, denies cigarette smoking and/or tobacco
chewing. Patient Wears seat belts all the time, is not depressed.
Fam Hx: Grandparents unknown, father unknown, mother headaches.
History questions asked:. List out each question you asked the patient/parent. This
is a focused exam unless a school or yearly physical.
1. How can I help you today?
2. When did your headache started?
3. What are the events surrounding the start of your headache?
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A CLAUSE REVIEW
4. Do you have any awareness or warning symptoms that occur before the
headache begins?
5. Where more precisely is the pain in your head?
6. What does the pain in your head feels like?
7. How long does your headache last?
8. How severe (0-10 scale) is your headache?
9. How often do you have headache like this?
10. Do you have nausea/vomiting?
11. Have you been having fevers?
12. Do you have sinus pain?
13. Do you have new weakness in arm, leg, or your face?
14. Does any think make your headache better or worse?
15. What treatments have you have for your headaches?
16. Have you had history of migraines?
17. Has anyone suffered from migraines in your family?
18. Anything new in your family medical history I should know about?
19. Tell me about the health of your grandparents, parents, and children?
20. Any previous medical, surgical, or dental procedures?
21. Have you ever been hospitalized for symptoms like the one you have
now?
22. Have you had any significant traumatic injuries or accident?
23. Are your immunizations up to date?
24. Do you drink alcohol? If so, how many drinks per day?
25. Do you use any recreational drug?
26. Do you now or have you ever smoked or chew tobacco?
27. Does any food seem to bring the headache on?
28. Have you noticed any blurred vision?
ROS:
GENERAL: Denies, fever, chills, weakness, or fatigue. Positive for weight loss.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No
palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum
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