A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had

them since she was a teenager, but they have become more debilitating recently. The episodes occur

once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the

right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing

sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain

including loud noises and movement. She has taken several over the counter medication like naproxen

and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet

room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals

her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms. Currently

a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the

Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck

stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations,

shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no

vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP

112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and

situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate

conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable

masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No

edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen

with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with

symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air

conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt.

says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve

intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles

reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to

complete heel to shin, gait steady.

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