History and Examination

Headache

Date of clerking: 11/1/2013

History of Presenting Illness

• Mr Y is a 40 years old Malay man with complains of sudden onset of headache since this morning when he woke up from sleep. He do not have any known co-morbid.

• The pain was throbbing on his right side of the head • The pain was constant. The severity of the pain was

4/10. • The pain was associated with visual disturbance.

Patient experience blurry vision . • Bright light would trigger his headache to become

worse. • No aura.

• However , the pain did not associate with any nausea , vomiting , weakness or sensory disturbance.

• Mr. Y did not had any fever or neck stiffness, but he do have neck tenderness.

• He do had sleep deprivation(sleep for 2 hours) last night because he being took care of his 3 month baby.

• He did not on regular painkillers.

History of Presenting Illness

Physical examination

• General examination:

– Pt conscious and alert.

– Vital signs:

• Capillary refill time <2 seconds.

• Pulse rate: 78 bpm with regular rhythm and good volume.

• Temperature: 37

• Blood pressure: 130/80 mmHg

• Respiratory rate about 16 breath per minute.

– Lung and airway are clear

– CVS: dual rhythm no murmur