Anamnesis

Identification: Sex/Age: Female, 58 years Medical History: Systemic arterial hypertension for 15 years (irregularly controlled), type 2 diabetes mellitus, dyslipidemia Medications: Losartan 50mg/day, metformin 850mg 2x/day, simvastatin 20mg/day Family History: Father with ischemic stroke at 65 years History of Present Illness (HPI): Main symptom: Chronic headache for 4 months Pain Characteristics: Location: Bifrontal Character: Constant pressure Intensity: 5-6/10 Course: Progressive, daily, without remission periods Associated symptoms: Occasional dizziness, bilateral tinnitus Risk factors: Poorly controlled hypertension (last BP 160/95mmHg), smoking (20 pack-years) Physical/Neurological Examination: General: Normotensive at the time of examination (130/85mmHg) Neurological: No motor or sensory deficits Normal and symmetrical reflexes Fundoscopy: Straightened arterioles with pathological crossings No meningeal signs Complementary Exams: Brain MRI: Moderate periventricular leukoaraiosis, chronic microangiopathy Brain MRA: Diffuse narrowing of small intracranial vessels Laboratory: Glycated hemoglobin 7.8%, LDL 130mg/dL

Report this case — e.g. suspected re-identification risk.