I. DATABASE:

- Identification:
Name: Miss. M (45 years old)
Address: Indonesian
Occupation: career women
- Ax:
Chief Complain: head aches
History of the present illness:
Ms. S. 45 years old, complained of pain, especially head,on the back of the head. Experienced headaches constantly, and no end. Sometimes not hurt, but sometimes hurt. His neck was stiff, like grip, his head felt like a stricken bound a heavy objects. Stress may aggravate a sense of soreness and stiffness in the neck. Not found weakness . blood pressure increased slightly. Not found nausea-vomiting. No visual impairment. No traumatic injury at the face.

History of the previous illnesses:
DM (-), HT (-)
General status:
Compos mentis, independent ambulation and a normal gait.

II. PHYSICAL DIAGNOSTIC
Blood pressure: 130 / 80
Pulse: 88 x / m
Head: a / i / c / d = – / – / – / – / –
Neck: nad
Chest: Cor: S1 S2 single, murmurs (-)
Pulmo: Vesicular respiration type

Extremities: Motoric: 5 5
5 5

Physiological Reflexes: BPR = +2 +2 KPR = +2 +2
PLA +2 +2 APR +2 +2

Pathological Reflexes: Babbinsky = – / –
Chaddock = – / –

Sensory Deficit: (-)
Local Status of The Face:
- Frontal Muscle: N
- Corrugator Muscle Supercillii: N
- Procerus Muscle: N
- Orbicullaris Oculli Muscle: N
- Nasalis Muscle: N
- Zygomaticus Major Muscle: N
- Bucinator Muscle: N
- Orbicularis Oris Muscle: N
- Mentalis Muscle: N

Lacrimation / Tear: (+)

III. PROBLEM LIST
Headache accompanied by stiff neck. The pain increases if she had stress

IV. Assessment
Tension-type headache

V. PLANNING
Diagnostic: (-)
Treatment: 1. Relax, rest and vacation multiply
2. Physiotherapy
3. Mefenamat acid, lightweight Transquilizer
4. Keep health