Emily Green – I-Human
Patient and Encounter
● Patient: Emily Green
● Reason for encounter: Evaluation of recurrent headache/migraine
● Primary concern: Headache consistent with migraine
● Setting: Outpatient primary-care clinic
● Relevant history: Recurrent headaches with associated migraine-type symptoms
History
General
● How can I help you today?
● When did the headache begin?
● Is this the first headache like this you've experienced?
● Have you had similar headaches before?
● How frequently do you get headaches?
● How long do your headaches usually last?
● Are the headaches becoming more frequent or severe?
● What makes the headache better or worse?
Headache Characteristics
● Where is the pain located?
● Does the pain occur on one side or both sides?
● How would you describe the pain?
● Is it throbbing, pulsating, pressure-like, sharp, or stabbing?
● How severe is the pain from 0–10?
● Did the headache begin suddenly or gradually?
● How long does the pain last?
● Does physical activity make the headache worse?
● Does rest or sleep improve the headache?
● Do you notice any particular triggers?
Associated Symptoms
● Do you experience nausea or vomiting?
● Are you sensitive to light?
● Are you sensitive to sound?
● Do you experience visual changes?
● Do you see flashing lights, spots, or zigzag lines?
● Do you experience numbness or tingling?
, ● Any weakness?
● Any difficulty speaking?
● Any dizziness or loss of balance?
● Any loss of consciousness?
Aura
● Do you experience visual symptoms before the headache?
● Do you experience numbness or tingling before the headache?
● How long do these symptoms last?
● Do the symptoms occur before the headache or during the headache?
Red Flags
● Did the headache reach maximum intensity suddenly?
● Is this the worst headache of your life?
● Have you had a recent head injury?
● Do you have fever or neck stiffness?
● Any confusion or altered mental status?
● Any new neurologic symptoms?
● Any new headache pattern?
● Does the headache wake you from sleep?
● Is the headache worse with coughing or straining?
Past Medical History
● History of migraines?
● History of neurologic disorders?
● History of seizures?
● History of hypertension?
● History of depression or anxiety?
● Previous head trauma?
● Previous diagnostic imaging for headaches?
Medications/Allergies
● What medications are you currently taking?
● What do you take when you get a headache?
● How often do you use pain medications?
● Any OTC medications?
● Any vitamins or supplements?
● Any medication allergies?
Menstrual/Reproductive History
● Do your headaches occur around your menstrual period?
Patient and Encounter
● Patient: Emily Green
● Reason for encounter: Evaluation of recurrent headache/migraine
● Primary concern: Headache consistent with migraine
● Setting: Outpatient primary-care clinic
● Relevant history: Recurrent headaches with associated migraine-type symptoms
History
General
● How can I help you today?
● When did the headache begin?
● Is this the first headache like this you've experienced?
● Have you had similar headaches before?
● How frequently do you get headaches?
● How long do your headaches usually last?
● Are the headaches becoming more frequent or severe?
● What makes the headache better or worse?
Headache Characteristics
● Where is the pain located?
● Does the pain occur on one side or both sides?
● How would you describe the pain?
● Is it throbbing, pulsating, pressure-like, sharp, or stabbing?
● How severe is the pain from 0–10?
● Did the headache begin suddenly or gradually?
● How long does the pain last?
● Does physical activity make the headache worse?
● Does rest or sleep improve the headache?
● Do you notice any particular triggers?
Associated Symptoms
● Do you experience nausea or vomiting?
● Are you sensitive to light?
● Are you sensitive to sound?
● Do you experience visual changes?
● Do you see flashing lights, spots, or zigzag lines?
● Do you experience numbness or tingling?
, ● Any weakness?
● Any difficulty speaking?
● Any dizziness or loss of balance?
● Any loss of consciousness?
Aura
● Do you experience visual symptoms before the headache?
● Do you experience numbness or tingling before the headache?
● How long do these symptoms last?
● Do the symptoms occur before the headache or during the headache?
Red Flags
● Did the headache reach maximum intensity suddenly?
● Is this the worst headache of your life?
● Have you had a recent head injury?
● Do you have fever or neck stiffness?
● Any confusion or altered mental status?
● Any new neurologic symptoms?
● Any new headache pattern?
● Does the headache wake you from sleep?
● Is the headache worse with coughing or straining?
Past Medical History
● History of migraines?
● History of neurologic disorders?
● History of seizures?
● History of hypertension?
● History of depression or anxiety?
● Previous head trauma?
● Previous diagnostic imaging for headaches?
Medications/Allergies
● What medications are you currently taking?
● What do you take when you get a headache?
● How often do you use pain medications?
● Any OTC medications?
● Any vitamins or supplements?
● Any medication allergies?
Menstrual/Reproductive History
● Do your headaches occur around your menstrual period?
