This is the first visit to the Clinical Center for this 38-year-old married, white woman who is a local attorney with GHI Corporation. The interview was obtained by M. White, a clinical student.
SOURCE AND RELIABILITY OF INFORMATION
The patient was cooperative and reliable. No other informants or data sources were available.
The chief concern is (1) headaches in the context of problem (2) difficulties with her boss. Other agenda items are (3) cough, (4) “colitis,” and (5) she wants to know if medications for colitis need to be added.
HISTORY OF THE PRESENT ILLNESS (HPI)
The patient's headache began rather suddenly at work 3 months ago. Headaches are accompanied by nausea during the last month and she vomited once last week during the most severe headache ever, which prompted this appointment.
The headaches are located diffusely over the right temporal region and do not radiate elsewhere. They feel deep within the head, are not associated with tenderness or increased sensitivity of the scalp, and are described as pounding and throbbing. They begin suddenly and then increase in intensity, described as “worse than having a baby” when severe. Ms. Jones has had to miss work a few days because of the intense pain. The headaches occur two to three times per week and can last as long as 12 hours at a time, although initially they occurred no more often than once weekly and lasted only a couple of hours. The headache is getting worse but seems to clear on the weekends when she is not at work. Nevertheless, the headaches have progressively worsened and are interfering with her life. Bright lights make the headache worse (photophobia). Lying in a dark room and placing an ice bag on her head seem to help. Drinking wine may also have been a precipitant once or twice. Nausea accompanies all headaches and she vomited a small amount of nonbloody material with one severe headache a week ago. The patient feels entirely well between her episodes of headache and nausea.
Except for a problem of being carsick a couple times as a youngster, there have been no other associated symptoms in neurological, gastrointestinal, or other body systems. In particular, there has been no loss of consciousness, change in vision, paralysis, stiff neck, rash, fever, chills, change in memory, or history of seizures. She feels well otherwise, has a good appetite, and enjoys outside activities. There is no history of joint pain or swelling.
An injection in the emergency room 1 week ago provided relief, but the exact medication is not yet known to us; only a blood and urine test were obtained, the results of which are not yet available. Except for no more than six to eight aspirin ...