Identifying Data
Source and Reliability of Information
Chief Concern/Agenda
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. Mrs. Jones has had to miss work a few days because of the intense pain. The headaches occur 2–3 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 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 6–8 aspirin daily and this one injection, she takes nothing for the headaches and has seen no other caretakers. Regarding possible causative factors, she has been taking birth control pills for 6 years and there is a possible history of migraine in an aunt. There is no history of head injury or neck injury. As noted below, the headaches seem clearly to be precipitated by stress she is having on the job.
Mrs. Jones’ headaches occur at times of conflict with her boss. She is the corporation’s new lead attorney and was brought in to replace the man who is now her boss, and promised there would be no problem during a year of transition prior to his retirement. He has been pushing and criticizing her, which makes her angry, and this leads to the headaches. She is also angry at the Board for promising that this problem would not occur. The relationship of anger and headache is similar to what she experienced as a child when her mother would unfairly criticize her. She believes her boss is the problem because, when she can avoid him, she has no headaches. Although she believes stress is a major precipitator of her headaches, Mrs. Jones also attributes her headaches to the possibility of having a brain tumor. This makes her even more anxious. She wants help with the headaches and coping with the stress because she is afraid they will adversely affect her and her family’s personal lives. She is considering leaving her job. She has friends who provide support at work and her husband is supportive, but he does not say much because he encouraged her to take the job. Mrs. Jones has been satisfied with her sexual life until the last 3 months when her interest has decreased. Sexual intercourse now occurs about once every few weeks, but was a few times a week before starting this job. She is not worried about this, thinks that it relates to her work problems, and was not interested in further discussing it.
Past Medical History
She was followed regularly by Dr. Jergens for ulcerative colitis (see Hospitalizations) and he also acted as her primary physician until she moved here 4 months ago, since which time she has seen no one except for one emergency room visit. Dr. Jergens urged her to get a primary care physician when she moved here.
Cough and stuffy nose 3 weeks ago with a slight persisting cough. There was no sore throat, earache, or fever and the cough is nearly gone. She took an over-the-counter cough medication for a week at the beginning, but does not recall the name.
Her first and only episode of urinary tract infection occurred in July 2003 with symptoms of increased frequency and dysuria. She felt well otherwise and there was no hematuria, fever, chills, or back pain. She received a 3-day course of trimethoprim/sulfamethoxazole tablets (twice daily) from an emergency room in Colorado, where they were vacationing, and was symptom free within 2 days.
Knows she had measles and chickenpox as child and thinks she had a mild case of the mumps.
There is no history of rheumatic fever, scarlet fever, diabetes mellitus, cancer, tuberculosis, heart disease, sexually transmitted infections, or stroke.
She has never received blood transfusions, insulin, digitalis, blood thinners, heart medications, or blood pressure medications.
Past injuries, accidents: Fracture of left ulna 21 years ago as the result of a fall. It was casted for several weeks, and there has been no problem since.
1999—She was hospitalized for 3 days, and a diagnosis of mild ulcerative colitis was made. She presented with a 3-month history of periodic loose stools with occasional blood and mild abdominal cramping. Tests for “parasites and other germs” were negative at the University Hospital in the city where she was attending law school. She was cared for by a Dr. Jergens. Colonoscopy led to the diagnosis of ulcerative colitis, and she was told she did not need surgery but to follow up closely, which she did at about 6-month intervals. She took prednisone for the first 3 months following discharge, starting at 40 mg daily and slowly reducing the dosage. She also took sulfasalazine, starting at 8 tablets daily (presumably 500 mg tablets but not yet verified). After 3 months, when the prednisone was stopped, the dose of sulfasalazine was slowly reduced to 4 tablets daily over the ensuing 3 months. This was stopped altogether a year later. She was asymptomatic until November 2010 when some diarrhea without blood developed. Colonoscopy by Dr. Jergens showed a mild flare-up. Again, no surgery was advised and she was treated with sulfasalazine (she brought this pharmacy label), 1.0 g qid for about 2 months. It was then gradually reduced to 0.5 g qid for 6 months and then it was stopped. There has been no recurrence of symptoms. At her most recent colonoscopy with Dr. Jergens 6 months ago, she was told her colon looked essentially normal and that nothing further was necessary except close follow-up.
Two uncomplicated vaginal deliveries 6 and 8 years ago, productive of healthy children. She was hospitalized less than 72 hours each time.
Tonsillectomy and adenoidectomy as a child.
She has had all of the usual “baby shots” but does not know exactly what they were. A tetanus shot was given 2 years ago following a puncture wound to the hand. She does not think flu shots work and does not want any more because she got sick after the last one 3 years ago.
