Huong Vo
NU 7451-G3-2021FA
Samantha Higgins H&P
Patient Information
Samantha Higgins is a 55 year old female.
History is provided by the patient,
... [Show More] who is a reliable source.
Chief Complaint
“Headache”
Present Illness
Samantha Higgins is a 55-year-old female who presents to the ED by ambulance with a chief complaint of a headache. She stated that she woke up from her sleep with a sudden, 9 out of 10, severe headache, that is all over and inside her head but worse in the back (as she places her hand on the occipital area). She told her husband call 911. In the ambulance she had one episode of vomiting. She states her headache is worse with any movement making it difficult to walk. She denies any head injury or trauma.
Past Medical History Uncontrolled Hypertension Occasional Tension Headaches
Bell’s Palsy (Right Side – 5 Years Ago)
Surgical History
Appendix at Age 12
Hospitalization
Appendix Surgery
Allergies
No Known Allergies
Health Maintenance
Immunization: Up To Date (as of 3 years ago)
Sexual History
Heterosexual
Family History
Mother is alive, 70, has diabetes and hypertension. Father died in a car accident at age 58.
No Siblings
Personal and Social History Lives in town with husband. Has Children (3 Live Births)
Works for a home improvement distributor.
Alcohol: Drinks 2 or 3 glasses after work during the week. A bottle on the weekends. Tobacco: Smokes a half pack a day. Has been smoking for 17 years.
Illicit-Drug Use: None
Medications
Ibuprofen for Headaches
Does NOT take medication prescribed for hypertension.
Review of Systems General: Refer to HPI.
HEENT: Reports pain all over head, inside the head, around the eyes, and worse at the back of the head. Reports sharp pain in head like it’s going to burst, light sensitivity, eye pain, and neck stiffness. Denies head trauma, loss of vision, blurred vision, double vision, ear pain, hearing loss, ringing in ears, neck pain, sore throat, and difficulty swallowing.
Cardiovascular: Reports having high blood pressure a couple years ago but does not take medications that was prescribed. Denies chest pain, heart palpitations, and peripheral edema. Respiratory: Denies cough, shortness oof breath, and wheezing.
Gastrointestinal: Reports nausea and vomiting. Denies blood or coffee ground vomitus, diarrhea, heartburn, abdominal pain, changes in appetite, and changes in bowel habits. Genitourinary: Denies change in bladder habits and any abnormal vaginal bleeding.
Musculoskeletal: Reports neck stiffness and difficulty walking due to headache. Denies fatigue, muscle pain, muscle cramping, and joint and bone pain and swelling.
Neurological: Reports headache and difficulty walking. Denies dizziness, trouble with speech, memory loss or problems, tremors, numbness, and [Show Less]