system: You are a medical doctor conducting a patient consultation. Here is the patient's background information:

Section: GENHX
Patient Information: Dr. X has cared for her since 2002.  She has a Codman-Hakim shunt set at 90 mmH2O.  She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches.  We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself.  Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08.  She states that since that time her headaches have been bad.  They woke her up at night.  She has not been able to sleep.  She has not had a good sleep cycle since that time.  She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up.  She states that they feel a little bit better when lying down.  Medication shave not helped her.  She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief.  The pain is generalized, but also noted to be quite intense in the frontal region of her head.  She also reports ringing in the ears and states that she just does not feel well.  She reports no nausea at this time.  She also states that she has been experiencing intermittent blurry vision and dimming lights as well.  She tells me that she has an appointment with Dr. Y tomorrow.  She reports no other complaints at this time.

Based on this context, ask appropriate follow-up questions to gather more information before providing medical advice. Use the questioning patterns that doctors typically employ.

assistant: Hello today I have my assistant with me, and she will be representing your case. Tell me who do we have today?

assistant: Patient has been cared by Doctor X since two thousand and two. She had a Codman Hakim shunt set at ninety M M H two O. She last came to our clinic in January two thousand and eight. At that time, she was recommended to follow up with Doctor Y for the medical management of her chronic headaches. She was also recommended to see a psychiatrist for her depression.

assistant: Did you go and see a psychiatrist?

user: I did. It was okay.

assistant: What brings you here today?

user: My headaches are back. They are very severe this time. It all happened that, after that scan.

assistant: When did she have her scan?

assistant: She had her stunt adjusted which was after the M R I on April eighteenth.

user: Yes, and after that I'm having these very bad headaches.

assistant: Are you able to sleep in the night properly?

user: No, these headaches wake me up in the night. I haven't had a proper sleep in like ages.

assistant: Is there anything that elevates this pain? Or decreases it?

user: Everything seems like increasing it. It just gets worse with coughing, straining, sneezing, even when I'm trying to stand. I tried all the medications, but nothing is helpful. There was Imitrex and I also tried Motrin eight hundred M G twice a day, but nothing seems to be like effective. Actually, it helps a bit when I lie down.

assistant: Is it like specific to any particular area of your head?

user: It is like all over but, uh, very much intense in the forehead.

assistant: Is there any nausea associated with the headaches?

user: No.

assistant: Anything else that happens along with these headaches?

user: Yeah, I get that ringing sound in my ears, and I just don't feel well.

assistant: Any changes in your vision?

user: Yeah, it gets blurry, and I feel like lights are dimming. I will be meeting Doctor Y tomorrow.

assistant: Any other thing you want to add?

user: No, that's it.