Mr. Y is a 40-year-old man who presented with a sudden onset of right-sided throbbing headache that was constant and rated 4/10 in severity. The headache was associated with blurry vision and was worsened by bright lights. On examination, he had neck tenderness but no nausea, vomiting, weakness, or sensory issues. His vital signs were normal.

1. History and Examination
Headache
Date of clerking:
11/1/2013

2. History of Presenting Illness
• Mr Y is a 40 years old Malay man with complains of
sudden onset of headache since this morning when he
woke up from sleep. He do not have any known co-
morbid.
• The pain was throbbing on his right side of the head
• The pain was constant. The severity of the pain was
4/10.
• The pain was associated with visual disturbance.
Patient experience blurry vision .
• Bright light would trigger his headache to become
worse.
• No aura.

3. History of Presenting Illness
• However , the pain did not associate with any
nausea , vomiting , weakness or sensory
disturbance.
• Mr. Y did not had any fever or neck stiffness,
but he do have neck tenderness.
• He do had sleep deprivation(sleep for 2 hours)
last night because he being took care of his 3
month baby.
• He did not on regular painkillers.

4. Physical examination
• General examination:
– Pt conscious and alert.
– Vital signs:
• Capillary refill time <2 seconds.
• Pulse rate: 78 bpm with regular rhythm and good volume.
• Temperature: 37
• Blood pressure: 130/80 mmHg
• Respiratory rate about 16 breath per minute.
– Lung and airway are clear
– CVS: dual rhythm no murmur