Lucilla Ladbroke

45 year old hair dresser

 

PC:      headache

HPC:    gradual onset during last 3 days

            yesterday N&V x3 (nausea and vomiting)

            mild photophobia for 1 day, but now has difficulties focussing +                 double vision

            pain mainly left parietal and frontal

            similar episode 16 years ago while travelling to Scotland    

            no  neck stiffness, no  fever, no  rash

PMH:   occasionally migraine (usually quite mild)

            ? IgA deficiency – never caused problems

            renal impairment due  to right kidney stone

            childhood eczema – now settled

            mitral valve prolapse

DHx:    paracetamol and ibuprofen for 3 days

            occasionally sumatriptan for migraine

            OTC (over the counter) vitamins and iron

FHx:     daughter: infectious mononucleosis recently, had thymoma aged 3

            father: myasthenia gravis

            twin sister: acoustic nerve neuroma

SHx:    lives with husband, 2 daughters and 3 parrots

            smokes 7 cigarettes per day, occasionally alcohol

            recently changed jobs to different employer