Sample Student Write-up
CC: I have a terrible headache HPI: A 21 year old female college student who is otherwise healthy presents with a headache that started 3 hours ago. Early this morning she was nauseated, without vomiting, and she experienced blurred vision in her right eye. Thirty minutes later, she developed an intense throbbing headache on the right side of the forehead with pain level of 10 out of 10. The pain was not relieved by 1000 mg of acetaminophen (two extra strength Tylenol). The pain is aggravated by bright lights and loud noises. The headache has been continuous in nature and was described as throbbing. She has no neck pain or stiffness. She has no history of head trauma. She has not had any stressors at or home or at school. She has previously had rare headaches with a pain level of 5 out of 10 without the nausea and blurred vision. Those headaches were relieved with acetaminophen. She has not seen any flashing lights. She has had not numbness or tingling in her extremities. She has not had a recent upper respiratory infection or nasal or sinus congestion. Her mother has a history of migraine headaches. Medical History: No chronic medical conditions, hypertension, diabetes or cancer. Reproductive History: She has been sexually active in the past but is not currently. She has no history of pregnancy. Periods began at age 12, are regular and last for 5 days. Surgical History: None. Medications: Oral contraceptive pill (Alesse). Acetaminophen as needed. No other over the counter medications or nutritional supplements. Allergies: No known drug allergies. Social History: She is single and heterosexual. She is not currently in an intimate relationship. She is majoring in English is doing well in school. She lives with two roommates. She does not use tobacco or alcohol or recreational drugs. She exercises regularly by playing intramural soccer. Family History: Her mother suffers from severe migraines. Otherwise her parents are healthy. Her older sister has depression. Her younger brother is healthy. She has no children. Her maternal grandmother died from a stroke at age 70. Her maternal grandfather has hypertension and is 75. Her paternal grandfather died in an MVA. Her maternal grandmother is healthy. Review of systems: General: No weight changes, sleeps well Skin: No rashes HEENT: See HPI. No sore throat, ear pain or hearing loss. Sees dentist yearly. Neck: No swelling or pain. Respiratory: No cough, wheezing, shortness of breath. Cardiovascular: No dyspnea, orthopnea, chest pain or palpitations. Gastrointestinal: See HPI. No diarrhea constipation or change in bowel habits. Urinary: No urinary frequency, urgency, hematuria or incontinence. Genital: No vaginal or pelvic infections. Musculoskeletal: No joint or muscle pain. Psychiatric: Mood is good. Neurologic: No fainting, seizures or loss of motor or sensory function. No memory or cognitive problems. Hematologic: No easy bruising or bleeding gums. No anemia. Endocrine: No temperature intolerance. No increased sweating. No polyuria or polydypsia.
Physical Exam: General: A thin young woman who appears in pain, sitting in a dark room with her head in her hands. Vitals: B/P: 118/74, pulse 72, respiratory rate 14, temperature 98.6 F Height: 55, Weight: 142 lbs. BMI: 24 HEENT: Head: normocephalic, atraumatic without tenderness.. Eyes: Visual fields intact by confrontation. Vision 20/20 bilaterally. Pupils equal round and reactive to light (PERRLA). Extraocular movements intact (EOMI). Conjunctivae pink and sclera white. Disc margins sharp without hemorrhages or exudates. Ears: tympanic membranes pearly grey with a good cone of light. Nose: Mucosa pink, septum midline. Mouth: oral mucosa pink. Good dentition. No tonsil hypertrophy. Pharynx without exudates. Neck: supple. Trachea midline. Thyroid not palpable. No lymphadenopathy. Lungs: Thorax symmetric with good excursion. Clear to auscultation. Resonant to percussion. Cardiac: Brisk carotid upstrokes without bruits. No jugular venous distension. Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Abdomen: Normoactive bowel sounds. Soft, nontender. Liver 7 cm by percussion in the midclavicular line. Spleen and kidneys not felt. Extremities: Warm, without edema. 2+ dorsalis pedis pulses. Neurologic: Alert and oriented to person, place, time and situation. Cranial nerves II XII intact. Motor: strength 5/5 in upper and lower extremities. Sensation to light touch, pinprick, vibration and proprioception intact. Reflexes 2+ in bilateral upper and lower extremities. Cerebellar: finger to nose, heel to shin and rapid alternating movements intact. Gait is steady. Romberg is negative. Assessment and Plan: Given the family history of migraine and the aura (nausea and blurred vision) prior to her headache with the absence of signs of neurologic dysfunction or infection, the most likely diagnosis is migraine. These headaches are different than her usual, tension type headaches. 1. Medication to stop the headache (such as sumitriptan). Consider prophylactic medications should headaches recur. 2. Educate patient to avoid precipitating factors (such as skipping meals or sleep deprivation). 3. Advise non pharmaceutical measures during attack as well such as resting in a darkened room and cool compresses to the head. For questions on accepted medical abbreviations, you can reference [Link]