IHUMAN Neurological Case ( Migraine Headache ) Complete Review
1. Patient Encounter
- History Taking:
- Patient Name: Emily Davis
- Age: 34
- Gender: Female
- Chief Complaint: "I've been having severe headaches and
vision problems for the past week."
- History of Present Illness (HPI): Emily reports that the
headaches started a week ago and have been progressively
worsening. The pain is described as a throbbing sensation,
primarily on the right side of her head. She also experiences nausea, sensitivity to light, and occasional blurred vision. The
headaches are not relieved by over-the-counter pain medications.
- Past Medical History (PMH): No significant medical history.
- Family History (FH): Mother has migraines. Father has
hypertension.
- Social History (SH): Emily is a non-smoker and does not
consume alcohol. She works as a graphic designer and spends
long hours in front of a computer.
- Review of Systems (ROS):
- Neurological: Severe headaches, blurred vision, nausea,
sensitivity to light.
- Cardiovascular: No chest pain, palpitations.
- Respiratory: No shortness of breath, cough, or wheezing.
- Gastrointestinal: No vomiting, abdominal pain, or changes in
bowel habits.
2. Physical Examination
- Vital Signs:
- Blood Pressure: 125/80 mmHg
- Heart Rate: 78 bpm
- Respiratory Rate: 16 breaths/min
- Temperature: 98.6°F