Lance Gill M.

Tolentino
MD-72222

NEUROLOGICAL HISTORY TAKING

Joan, a 22-year old female, single, right-handed, first-year medical student, Catholic from Pasig
City, complains of chronic headache.

HISTORY OF PRESENT ILLNESS

Joan has been complaining of daily headaches, characterized as dull, non-throbbing bilateral
pain along the frontal and temporal areas since the start of the Enhanced Community
Quarantine (ECQ) in Metro Manila (12 weeks PTC). While the pain was noted to be distressing
enough to impair her ability to commit to academic and volunteer work, it was still manageable
and tolerable until the last week of the Modified Enhanced Community Quarantine (1 week
PTC) when the pain acutely progressed in intensity, described as intense, deep, throbbing, and
squeezing, which eventually prompted her to seek consultation. She was supposed to consult at
5 weeks PTC but deemed it risky because of the pandemic. Precipitating factors include stress,
heat, and dehydration, often peaking between 1-3 pm, and pain was also described to be most
intense during menstruation. Pain is oftentimes relieved through sleep and subsides in the
evening and early morning. There has been no fever, any symptoms of infection, remarkable
bodily pain, or physical trauma since the start of the ECQ. 

Temporal Profile 

Temporal Profile of Headache Intensity

Intensity on Pain Scale
10
9
8
7
6
5
4
3
2
1
0
12 11 10 9 Weeks 8 Weeks 7 Weeks 6 Weeks 5 Weeks 4 Weeks 3 Weeks 2 Weeks 1 Week
Weeks Weeks Weeks PTC PTC PTC PTC PTC PTC PTC PTC PTC
PTC PTC PTC

REVIEW OF SYSTEMS
There is no fever, but there is weight gain, increased appetite, and periods of easy fatiguability.
She does not complain of muscle and joint pains and there are no rashes or any remarkable
skin lesions.
There are no changes in vision, hearing, and balance. 
There is no difficulty in breathing and chest pains and no coughing, sneezing, and other
pertinent symptoms of respiratory infection.
She does not complain of nausea and vomiting or any changes in bowel movements.
She does not complain of any urinary problems. 

PAST MEDICAL HISTORY

Joan has no known medical conditions but was hospitalized twice during elementary school
from dengue and food poisoning. She has no maintenance medications, no allergies to food and
medicine, and has not undergone surgeries. She does not have any history of significant trauma
and did not report of any infection prior to the ECQ period. She has no known neurologic
conditions and did not have prior consultations for mental health illnesses.

FAMILY MEDICAL HISTORY 

One of her siblings was diagnosed with major depressive disorder and generalized anxiety
disorder. The only known neurologic disease in her family is Alzheimer’s disease which has
affected her paternal grandmother. She observed that her mother and two of her siblings have
recurrent migraines. There is also a strong family history of colorectal cancer which was the
cause of death of her mother and two of her maternal aunts. 

PERSONAL, TRAVEL, AND SOCIAL HISTORY

Joan is currently a first-year medical student and is determined to be promoted to second year.
She only keeps a small number of close and trusted friends,but is able to interact well with her
peers. Her sources of stress include her academic workload, family concerns and dynamics,
and most especially, the current COVID-19situation in the country. She did not have any
prolonged or close interactions with other people. She has not traveled outside the country for
five years now. During the ECQ period, she only goes out once a week for groceries. She is
currently residing alone in her condominium unit, but prior to the ECQ, she shared the place
with two other medical students. She does not have any vices and is averse to alcohol,
cigarettes, and drugs. She prefers to drink tea and rarely drinks coffee or energy drinks. She
does not, however, perform routine exercise and reports to have bad eating habits such as
eating irregularly and infrequently and consuming processed foods more than home-cooked
meals. 
APPENDIX:

Figure 1. Pain Scale used for reporting pain. Patient reported pain levels between 3-4 until the
last week of the MECQ period where she reports a 6-7.