A Medical Paper, Interview Example

Ms Jones is a 46-year-old female who presented with a chief complaint of “I have had such a bad headache for the past 24 hours.”The patient states that she also has visual disturbances.  She is also positive for nausea and vomiting.  She requests that the lights be turned off as they are irritating to her eyes.  She has muscle aches as well.  The patient is a well-developed and well-nourished female in moderate distress.

The patient’s vital signs are BP 90/60; pulse 110; RR 18; temperature 99.0; O2 99% on RA; and FS 80.

There was no medical history available of the patient that could be used as a reference point.  I would have to rely solely on the details of the history of her present illness (HPI) as given by her and my physical and verbal examination.  I asked her if she had these symptoms before to which she replied in the affirmative.  I asked, “How long have you had such symptoms?  She replied that some of the symptoms appeared in the spring.  She said the first symptoms she really noticed were those of a stuffy nose and also of a dripping nasal drainage, along with a low-grade headache, all of which she put down to spring time allergies and possibly sinusitis as well.  The symptoms would disappear after approximately 24 hours, which was a relief because she was unable to obtain any restful sleep while they existed. At this point, I told her that I was going to examine her to help me make a good diagnosis.

The findings are as follows:

General – She tires quite easily and is often nervous.  Her weight has been stable at 125 lbs, which is a good weight for a middle-aged 5’4”female.  She does not work out, but she goes for 45 minute walks four times a week. She has had high cholesterol readings, but no meds.

Skin—Clear and smooth, but with some bruises.  Aspirins are her painkillers.

Head – She has bad throbbing headaches on the right side of her head.

Eyes—Lights irritate her eyes, and her vision is sometimes distorted.

Nose—Is often stuffed or dripping.

Mouth—unremarkable.  Teeth are clean and well kept.

Neck—No enlarged glands or nodes, but there is tension in it.

Respiratory – Everything checks out fine.

Cardiovascular—Pulse is somewhat elevated at 110, but it is strong and regular.  Patient has no history of cardiovascular problems.  Her low blood pressure concerns me somewhat.

Gastrointestinal—Positive for nausea and vomiting.  No history of ulcers.

Urology—No problems urinating and no history of bladder infection.

Musculoskeletal—Her muscles are painful periodically.  Tender areas are found.

Only medications are Aspirin.  No known allergies.  Mother also has throbbing headaches.

Social, family, and work life are positive experiences.

Diagnosis:  Moderate Migraines.  This is substantiated by the patient’s throbbing headaches on the right side of her head that she has been getting since spring and that usually last around 24 hours.  At such times she is positive for nausea/vomiting.  Lights  irritate her eyes and sometimes she sees flickering lights.  Patient also has trouble sleeping.