Description

TJ is a 20-year-old female with PMHx of chlamydia infection six months ago. She presents with headaches which occur 3 times weekly. States headaches are more frequent, last longer, and can cause stiff neck muscles. Headache typically responds to OTC ibuprofen and acetaminophen. Denies head trauma. Normocephalic, atraumatic, and no photophobia upon exam. Denies fever, numbness/tingling, or visual changes. Patient lives with boyfriend and is financially dependent on boyfriend since her job loss. Strained family relationships. Recent ED visit for circumferential wrist pain which did not match MOI. Patient appears withdrawn, poor eye contact, and evasive answers. Patient has bruising on left arm and left breast.
Patient smokes 1/2 pack/day. Patient is sexually active with boyfriend with intermittent condom use. No family history of migraines.