Case Study: Chief Complaint
Chief Complaint
Followup for inpatient stay for "complicated migraine".
History
Patient is a 54-year-old right-handed white female who has a long history of migraine headaches. She states she had headaches as a child. When she started having her menses, they became menstrually related. It would also occur during ovulation. For a while, she was on Topamax and other medications. She went through menopause four years ago with a marked decrease in her migraine frequency. She did note that in her 30's, she had two to three episodes of a migraine with right-sided sensory loss. With the first one, she was admitted for a CVA workup, which was negative. She does not get scintillating scotomas or aphasia with her headaches. She can use Imitrex to get rid of the migraine headache, and …show more content…
Hypothyroidism.
Multiple lumbar surgeries.
Appendectomy.
T&A.
Cholecystectomy.
She had peritonitis with adhesions, small-bowel obstruction, ureter obstruction, requiring surgery for adhesion lysis.
Allergies
Neurontin.
Medications
Butrans, atorvastatin 10 mg, Singulair, Lasix, levothyroxine, metformin, hydrochlorothiazide, losartan, tramadol, naproxen, sumatriptan,
Physical Examination
Constitutional
Weight 186 pounds. Height 5'5". Respirations 14. Pulse 69.
General
She is in no obvious distress.
Mental Status
She is oriented x3, alert, cooperative. Good short term, long term, and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration.
Cranial Nerves
Visual fields full to confrontation. Extraocular motions intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvula were midline. Normal auditory acuity. Normal shoulder shrug.
Motor
Was 5/5 all four extremities with normal tone.
Sensory
Was intact to primary modalities.
Cerebellar
Revealed good finger-to-nose, heel-to-shin, and rapid alternating motion.
Gait
Normal. Negative Romberg.
DTRs
2+ throughout. Toes are downgoing.
Followup for inpatient stay for "complicated migraine".
History
Patient is a 54-year-old right-handed white female who has a long history of migraine headaches. She states she had headaches as a child. When she started having her menses, they became menstrually related. It would also occur during ovulation. For a while, she was on Topamax and other medications. She went through menopause four years ago with a marked decrease in her migraine frequency. She did note that in her 30's, she had two to three episodes of a migraine with right-sided sensory loss. With the first one, she was admitted for a CVA workup, which was negative. She does not get scintillating scotomas or aphasia with her headaches. She can use Imitrex to get rid of the migraine headache, and …show more content…
Hypothyroidism.
Multiple lumbar surgeries.
Appendectomy.
T&A.
Cholecystectomy.
She had peritonitis with adhesions, small-bowel obstruction, ureter obstruction, requiring surgery for adhesion lysis.
Allergies
Neurontin.
Medications
Butrans, atorvastatin 10 mg, Singulair, Lasix, levothyroxine, metformin, hydrochlorothiazide, losartan, tramadol, naproxen, sumatriptan,
Physical Examination
Constitutional
Weight 186 pounds. Height 5'5". Respirations 14. Pulse 69.
General
She is in no obvious distress.
Mental Status
She is oriented x3, alert, cooperative. Good short term, long term, and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration.
Cranial Nerves
Visual fields full to confrontation. Extraocular motions intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvula were midline. Normal auditory acuity. Normal shoulder shrug.
Motor
Was 5/5 all four extremities with normal tone.
Sensory
Was intact to primary modalities.
Cerebellar
Revealed good finger-to-nose, heel-to-shin, and rapid alternating motion.
Gait
Normal. Negative Romberg.
DTRs
2+ throughout. Toes are downgoing.