Description

A. C. is a 20 y/o female with PMHx of Chlamydia infection about 6 months ago who presents with headache which occurs 3x/week. States headaches are more frequent and lasting longer. States headache can cause stiff neck muscles. States headache typically responds to OTC APAP/IBU. Denies trauma to head. Normocephalic, atraumatic, no photophobia manifested on exam. Denies vision changes. Denies fevers/numbness/tingling. Pt. is currently unemployed, lives with boyfriend and is financially dependent on boyfriend. Estranged from family. Frequent ED visits including last week was seen for circumferential wrist bruise. Pt. appears withdrawn, poor eye contact, evasive answers. Pt. has bruising on left arm and left breast. Pt. smokes a 1/2 PPD. Pt. is sexually active with boyfriend with inconsistent condom use. No family Hx migraines.